This investigation emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk. The report puts forward recommendations aimed at driving national improvement to reduce potentially fatal medication errors.

Please note that this investigation has previously been known as ‘Wrong route administration of an oral drug into a vein’.

Investigation summary

The investigation was launched after we were made aware of a nine-year old child wrongly administered an oral liquid drug into a vein during a planned renal biopsy. This is classed as a wrong route medication error. Administration of medicine via the wrong route is defined as a ‘never event’ in the NHS. A never event is a serious incident that is entirely preventable. The child stayed in the hospital for monitoring and was discharged with no adverse effects a day later. 

The investigation reviews: 

  • The effectiveness of current processes for the storage of medicines.
  • Equipment design.
  • The prescribing, preparation, checking and administration of medication. 

It also considers the:

  • Contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein.
  • Effectiveness of current processes for implementation of local safety standards for invasive procedures.

Safety recommendations

We’ve made safety recommendations to NHS Improvement (NHSI) and the Royal of College of Physicians (RCP) as a result of this investigation.

Recommendation 2019/028

It is recommended that NHS Improvement, through the National Patient Safety Alert Committee, set standards for all issuers of patient safety alerts which make clear that alert issuers should assess for unintended consequences of the actions in the alert, the effectiveness of barriers created by these actions, and provide appropriate advice for providers on implementation, include ongoing monitoring.

Recommendation 2019/029

It is recommended that NHS Improvement support the development of necessary knowledge, skills and capacity for the effective operationalisation of hazard identification and risk analysis at a national, regional and local level, as an integral part of the National Patient Safety Strategy.

Recommendation 2019/030

It is recommended that the Royal College of Physicians, in collaboration with the Royal Pharmaceutical Society, British Pharmacological Society, Royal College of General Practitioners, Royal College of Paediatrics and Child Health, NHS Improvement, the professional bodies for the professions regulated by the Health and Care Professions Council, Royal College of Nursing and Royal College of Midwives, provide leadership in recommending the postgraduate learning needs and activities to standardise professional development in medicines safety processes.

Recommendation 2019/031

It is recommended that NHS Improvement undertake a formal evaluation of banding, time and resource given to the Medication Safety Officer role across England and publish its findings and mandate minimum resources and standards.

Safety observations

This investigation makes the following safety observations:

  1. It is recommended that staff with a responsibility for medicines safety, for example Medicines Management and Chief Pharmacists, Clinical Governance Leads, Heads of Medicines Optimisation and Medication Safety Officers are familiar with the contents of the existing National Institute for Health and Care Excellence clinical guidance on medicines optimisation and can demonstrate how they have implemented the quality standard on medicines optimisation [QS120] and quality statement 3, ‘Learning from medicines-related patient safety incidents’.
  2. It would be beneficial to define a national standard for independent two-person checking when preparing high-risk medication for administration to minimise medication errors associated with high-risk medications.
  3. Availability of oral/enteral syringes in all clinical areas (in accordance with the requirements contained in the National Patient Safety Agency’s Patient Safety Alert 19) is inconsistent. A national audit tool may be helpful to organisations.
  4. Colouring of high-risk and/or oral liquid medications (such as midazolam) may have a justifiable role in improving safety as it will offer a signal to differentiate oral from parenteral preparations.
  5. It would be beneficial if potential interventions designed to reduce wrong route administration medication errors were subjected to human factors testing, review, evaluation and modification prior to being introduced at scale; this includes standards, processes, and the design of medication and administration devices.
  6. SCRIPT is an eLearning programme to improve safety and competency among healthcare professionals around prescribing, therapeutics and medicines management. It would be beneficial to roll out SCRIPT as a mandatory requirement for all prescribers.
  7. There is an opportunity with the new General Medical Council Medical Licensing Assessment to mandate additional therapeutic practical skills for example, the practical aspects of medicines administration, as part of the Clinical Practical Skills Assessment.

Safety observations are made when there is insufficient or incomplete information on which to make a definitive recommendation for action, although findings are deemed to warrant attention.