SAQ 285 – Administration – investigating a medication-related critical incident

Administration – investigating a medication-related critical incident.

a. Incident management actions

• Open disclosure to the patient and family.
• Investigate the event by reviewing records and interviewing staff.
• Report through the electronic incident system, RCA process, and medicolegal channels as appropriate.
• Educate and provide feedback through debriefing, M&M, counselling, and formal recommendations.

b. System contributors

• No mandatory or reliable process for recording allergies.
• No functional alert system, such as electronic prescribing allergy alerts.
• No mandated allergy check or double-check before drug administration.
• Shift length, roster pattern, overcrowding, or inadequate senior supervision.

c. SMART recommendation characteristics

• Specific: clearly defines what needs to be done, how, and why.
• Measurable: allows later measurement of completion or effect.
• Achievable/attainable: realistic within the setting.
• Relevant/result-driven: linked to a clear intended outcome.
• Timely: includes realistic but meaningful timeframes.

d. Barriers to change

• Organisational culture, silos, tribalism, or stakeholder resistance.
• Scarce staffing, financial, or IT resources.
• Leadership instability, competing demands, or large scale of the proposed change.