Aim To assess whether the introduction of a standardised medicines management pathway could reduce medication incidents in a tertiary NICU.

Methods Failure of an existing incident management process to favourably impact upon persistently high rates of reported medication errors prompted the development of a novel local medicines management pathway. The pathway was piloted in our tertiary NICU in June 2012, following which an accountability sheet was developed. This required nurses to verify at handover that all medications/infusions had been correctly administered thus ensuring that any errors were acknowledged and corrected within 12 h. The pathway was adapted to incorporate the accountability sheet and implemented in finalised form in August 2013.

In the event of an error occurring the senior duty nurse and doctor immediately grade level of error according to a set of predefined criteria regarding risk/harm to the infant. The error is corrected and staff debriefed. Details are recorded on a ‘Minor Medication Incident’ card

If the error is graded moderate or major or if there are frequent recorded minor errors, the senior clinicians will complete a formal incident report and instigate the management pathway i.e. formal letter/SBAR statement. During a debrief interview further training & education needs will be addressed.

A record of all errors/omissions is stored locally to identify trends and for audit purposes.

An enhanced ‘appropriate responsibility’ as opposed to a ‘no blame’ culture evolved allowing earlier intervention to manage those staff with risk-taking behaviours. This process also focussed staff on systems problems rather than individual errors. A record of prescribing errors, not previously captured, was developed. Appropriate pathways to support/retrain staff involved in moderate/major errors were identified.

Conclusions Existing trust wide clinical governance processes are languid and feedback to staff is not always followed through. The introduction of a local reporting and feedback mechanism has improved patient safety, enhanced a team responsibility culture and provided more time to manage serious clinical incidents.

Medication errors can be prevented and reduced by concentratinging on the medicines management system as a whole, rather than the individual practitioner in isolation.