Q5a. Help

Were there other important factors? If so, please select one or more from the following choices


Use this question to identify other factors that may have contributed to the medication error. Please select any that apply. If none of the categories accurately describes the additional factors, please select Not applicable and supply further explanation in the text box

Failure to refer for hospital follow-up

The medication was used under shared-care guidelines and changes in the patient response to the medication were not referred to the initiating consultant for further follow-up.

Poor transfer / transcription of information between paper and / or electronic forms

There was poor transfer of information from one paper form or electronic system to another, resulting in miscommunication about a medicine between different healthcare professionals.

Poor communication between care providers (verbal or written)

There was poor communication concerning an individual patient's medicine, eg, between primary and secondary care.

Use of abbreviation(s) of drug name / strength / dose / directions (eg, MTX, .1mg, 1po)

The error related to the use of abbreviations in prescribing or record-keeping (and including administration charts), eg, g or ISDN (Isosorbide Dinitrate).

Handwritten prescription / chart difficult to read

Omitted signature of healthcare practitioner

The healthcare practitioner prescribing, supplying, dispensing, preparing or administering a medicine failed to sign the prescription form or other appropriate healthcare record.

Patient / carer failure to follow instructions

Example The patient fails to follow the minimum time period between doses of analgesia, due to lack of pain control.

Failure of compliance aid / monitored dosage system (MDS)

Unit doses packed within these appliances are incorrectly or inappropriately prepared, eg, the dose is one tablet but two are packed within each compartment or blister.

Failure of adequate medicines security (eg. missing CD (controlled drug))

The medicine cannot be located when a dose is due to be administered due to poor or non-existent management of medicines storage.
A routine count of the controlled drug stock takes place and one or more drugs are found to be missing.

Substance misuse (including alcohol)

There is covert use of prescribed (eg, morphine, temazepam) or non-prescribed medication (eg, heroin, ecstasy), or alcohol, concurrent with NHS treatment and care.

Medicines with similar looking or sounding names

An incorrect medicine is prescribed, supplied or administered because the names sound alike, or appear alike if not clearly written.

Poor labelling and packaging from a commercial manufacturer

An incorrect medicine or strength / formulation of medicine is supplied, prepared or administered, due to close similarity to other medicine products supplied by an individual manufacturer. This may include same corporate logos, same pack or font size, or no colour differentiation between strengths.

Healthcare practitioner undertaking supplementary prescribing

Involves a professional with supplementary prescribing rights, such as a nurse or pharmacist.

Variance to guidelines for sound clinical reasons

National or local guidelines for the prescribing of a particular medicine have been varied or ignored. This may include unlicensed use of the medicine.

Involving a medicine supplied under a Patient Group Direction (PGD)

An error occurred with a prescribed medicine due to the concurrent use of a medicine supplied under a PGD. (This is a specific written instruction for supplying and administering a named medicine or vaccine in an identified clinical situation, eg, providing emergency hormonal contraception through sexual health clinics or pharmacies.)

Involving an over-the-counter (OTC) medicine

An error occurred with a prescribed medicine due to the concurrent use of OTC medication.

Failure in monitoring / assessing medicines therapy

The monitoring of a patient taking a specific medicine, eg, warfarin, is not adequately conducted. Or the results from such tests are not reviewed and assessed accurately, and the necessary therapy changes are not implemented.

Failure of clinical assessment equipment

The equipment used to support diagnosis or monitoring of a medication does not work properly, eg, peak flow meter.

Issues associated with an infusion pump / syringe driver

An infusion pump or syringe driver is involved in delivering the wrong medicine, dose or rate of administration.

Failure to order laboratory test

The medication is known to require laboratory tests to ensure its safe use, but a test is not ordered at the required time or interval.



Not applicable