Controlled Drug Incident Reporting Form

Please refer to Guidance and Example prior to completing

Name of
Pharmacy/Practice /

Any Pharmacy

Address / 25 Any Road
AnyTown
AN11 TOW
Contact phone No / 01234 5678910
Email Address /
Name of person completing form / Any Person
Date of Incident / 1st July 2016
Type of Incident / Please tick the type of incident you are reporting in the relevant box/boxes below.
Prescribing error / Drug
☐ / Strength
☐ / Form
☐ / Dose
☐
Quantity
☐ / Omitted drug
☐ / Other – please state
Dispensing error / Drug
☒ / Strength
☐ / Form
☐ / Dose
Quantity
☐ / Omitted/delayed drug
☐ / Other – please state
Labelling/Recording error / Patient
☐ / Drug
☐ / Strength
☐
Form
☐ / Dose
☐ / Directions
☐ / Other – please state
Collection/Delivery error / Wrong patient
☐ / Omitted/Delayed
☐ / Other please state
Wrong address
☐ / Lost/missing
☐
Loss/Theft/Spill / Loss
☐ / Balance Discrepancy
☐ / Destruction error
☐
Other please state / Theft
☐
Generic drug name prescribed / Methadone 1mg/1ml Oral Solution
Brand name of drug prescribed / Not applicable
Generic drug name dispensed / Methadone 1mg/1ml Oral Solution Sugar Free
Brand name of drug dispensed / Not Applicable
Detailed description of Incident
Please include what happened, who was involved, why it happened and also if it is a patient safety incident. / Patient submitted a prescription for Methadone 1mg/1ml Sugar Free oral solution. A dispensing error occurred and the patient was inadvertently supplied with Methadone 1mg/1ml Oral solution in error. This was noticed when the stock bottle was returned to the CD cupboard. There was no second accuracy check carried out due to staff shortages.
The incorrect product was selected by the pharmacist in error as the bottles are very similar and these had not been clearly separated in the CD cupboard.
The incorrect item was retrieved from the patient and the correct product supplied. The register balances were updated and the pages annotated with footnotes to reflect the error and balance discrepancies. The returned item was clearly marked and segregated from the CD stock items, awaiting witnessed destruction. This quantity is included in the register running balance.
No patient harm.
Immediate action taken to rectify the incident / The pharmacist attempted to contact the patient by phone immediately the error was identified. The patient did not answer the phone, so the pharmacist went to the patient’s home address to attempt to retrieve the incorrect supply.
The patient had not taken any of the incorrect supply so this was a no patient harm incident.
Once the incorrect item had been retrieved, the patient was supplied with the correct product and an apology issued..
The prescriber was contacted to inform them of the error.
Actions taken to prevent reoccurrence of a similar event /
  1. To update SOP to reflect changes to practice following this incident and ensure ALL staff work to the current version
  2. To clearly separate the two similar products in the CD cabinet, and in future we will highlight the Sugar Free product to aid correct product selection.
  3. To check the product selected against the prescription prior to dispensing.
  4. To obtain a second accuracy check prior to handing out to the patient, where ever possible, otherwise take a mental break and double check again
  5. To confirm the expected dose and product with the patient and confirm against the prescription and product prior to handing out.
  6. To promptly enter issue into CD register to enable balance to be reconciled and act as an additional check the correct product has been issued.
  7. To flag patient recordto indicate an error occurred and to act as an aide memoir for future prescriptions.

Lessons learnt
Please include a detailed description of what will you do differently in future, what actions or changes to process/procedure you have put in place /
  1. To always check the product selected against the prescription (and not the label generated)
  1. To obtain a second/accuracy check prior to issuing to patient where ever possible.
  1. To clearly separate similar products in the CD cupboard and highlight the Sugar Free Product to help aid correct selection.
In addition for all CD issues remind the team:
  1. When counselling the patient to ask for confirmation of the expected dose and product and confirm this against the prescription, to act as an additional check.
  2. To promptly enter issues into register and reconcile balances against register on a regular basis.

How will this incident be shared with the wider team / An organisational incident report had been submitted for NRLS and details shared with CDAO.
This incident and expected future actions has been shared with the team at the weekly staff huddle.
Minutes of this meeting were taken and these have been shared with temporary/locum staff to make all aware.
SOPs have been updated to reflect the additional requirements when handling Methadone and other CDs.

Incidents Reports should be completed and emailed to

Guidance on completing the ‘Controlled Drug Incident Reporting Form’

Summary

It is a legal requirement for all Controlled Drug (CD) related incidents to be reported to the Lead Controlled Drugs Accountable Officer (CDAO). Responsibility lies with the Lead CDAO to oversee the use of CDs in their geographical area, to ensure safe and legal use, and to share trends and occurrences with the Controlled Drug Local Intelligence Networks. (CDLINs)

Your assistance in fully completing the ‘Controlled Drug Incident Reporting Form’ is required. This provides the CDAO team with the necessaryinformation to investigate CD incidents, gain assurance that changes to practice have been identified and implemented, and to share the learning with CDLINs and the wider audience. If additional information is required, we will contact you.

What we need from you please:

  • The full address and name of the pharmacy/practice, as there may be more than one pharmacy/practice with similar details.
  • Complete the contact details in full:this allows us to contact the correct person should more information be required.
  • The date of the incident is required to make a timely investigation and conclusion to the event.
  • Mark the necessary box/es to indicate the type of incident. This provides trend data.
  • Indicate the drugs involved.This allows us to identify if a problem is occurring with a particular drug or brand. It is NOT necessary to provide the brand/trade name, if this is not applicable to the incident.
  • Give a summary of the event, stating clearly what happened, why it happened and who was involved. If patient safety was at risk then details should also be included.
  • Details of the immediate actions taken to resolve the situation. Bullet points are helpful
  • Details of the actions that will be taken to prevent this from happening again. Bullet points are helpful
  • The learning acquired from investigating the incident, this is very important. We would like to share any learning with others.
  • Details of how the incident was shared with others

The CDAO and team thank you for your assistance in providing the required information. Any learning identified from investigations that can be shared with others will be anonymised.

Additional Resources can be found:

Root Cause Analysis (RCA) report-writing tools and templates