Source · HSSIB Patient Safety Investigation
Medicine omissions in learning disability secure units
Published 15 April 2021
Launched 30 September 2019
Published
HSIB Legacy
Medication
Access to care
This healthcare safety investigation looks at patients on learning disability secure units who do not receive medicines that have been prescribed to them.
Summary
2 recommendations
3 observations
2 of 2 responded
Safety Recommendations
R/2022/198
NHS England
HSIB recommends that NHS England and NHS Improvement reviews and updates all health building guidance relating to learning disability secure units to reflect current clinical guidance on ensuring the design and layout provides a suitable environment for patients and staff.
NHS England has drafted supplements to Health Building Notes 03-01 and 03-02, engaging with relevant programs to ensure inclusivity in secure units. These supplements are targeted for publication by the end of 2023, which will meet the recommendation.
Response received 16 October 2023
Health Building Notes give best practice guidance on the design and planning of new healthcare buildings and on the adaptation or extension of existing facilities They provide information to support the briefing and design processes for individual projects in the NHS building programme. Our forthcoming supplements to Health Building Note (HBN) 03-01 and HBN 03-02 on medium and low secure units have been drafted after engagement with NHS England’s Learning Disability and Autism Programme and the National Development Team for Inclusion (NDTi) to ensure that all low and medium secure units are as inclusive as possible. Clinical leads agree that if designing a specific Learning Disability secure unit, the guidance in the current HBN would be appropriate. Therefore, we will meet the recommendation R/2022/198 once the supplements to HBN 03-01 and HBN 03-02 supplements are issued (targeted to be ready by the end of the year). Actions planned to deliver safety recommendation: Publish final version of HBN 03-01 Supplement 1 Medium and low secure mental health facilities for adults and HBN 03-02 Supplement Medium and low secure mental health facilities for children and young people, by 31 December 2023 (target). Response received on 16 October 2023.
R/2022/199
NHS England
HSIB recommends that NHS England and NHS Improvement develops the ongoing work to improve the retention of learning disability nurses, in line with the intent of the All-England plan for learning disability nursing.
NHS England details ongoing initiatives from their ‘All England plan for Learning Disability Nursing’ to improve retention. These include a new early career fellowship, enhanced awards, and a training package, all aimed at professional development and workforce engagement.
Response received 1 September 2022
We welcome the publication of this report which readily identifies some valuable points of learning for our health and care system. As part of our ongoing commitment to addressing the challenges for the learning disability nursing profession, in March 2020, NHS England in joint partnership with Health Education England published the ‘All England plan for Learning Disability nursing’. The plan is to be delivered over 5 years and is founded on the four guiding principles of Attract, Retain, Develop and Celebrate. Each principle is supported by an array of dedicated workstreams, and our overarching ambition to increase the number of learning disability nurses entering the profession, while retaining those currently in practice. In respect of the HSIB report: Medicine omissions in learning disability secure units. Our ‘retain’ principle includes a number of workstreams, each of which are aimed at improving the retention of learning disability nurses. A particular focus of our retain work is aimed at delivering a new continuing professional development offer for the learning disability nursing workforce. This includes the introduction of a new early career fellowship which we have developed in partnership with the Foundation of Nursing studies. The aim of the fellowship is to engage early career learning disability nurses, who have been qualified between 1-4 years, to develop skills and competencies in transformational leadership and culture change. A further workstream relates to the creation of three new enhanced awards for learning disability nurses working in either, specialist inpatient settings, specialist community settings, or within acute and primary care. Our aim in creating these programmes is to provide mid-career learning disability nurses with the opportunity to hone their expertise in one of three specialist areas of practice, and in doing so, generate additional expertise, knowledge, and skills. In addition to the above, we are currently designing a training package which will be available to both mental health and learning disability nurses. The training will equip both of these groups of nurses with an enhanced knowledge about the mental health needs of people with a learning disability. The training will enhance collaborative working across these fields of practice and will serve as a useful incentive for retaining those nurses who are seeking further career advancement and qualifications. Prior to the advent of the All-England plan for Learning Disability Nursing there was a paucity of professional development opportunities available to learning disability nurses across the career trajectory. As such, these new offers, all of which are funded, are reinvigorating the learning disability nursing workforce, and are supporting retention. In addition to these workstreams, a key focus of the plan is to create a social movement for change for learning disability nursing, and to help achieve this we have established a bi-annual learning disability nursing symposium, a new national website for learning disability nursing, and a host of other initiatives all of which are aimed at engaging with and raising the profile of the profession. View a copy of the All-England Plan for Learning Disability Nursing . Response received on 1 September 2022.
Safety Observations
Observation 1
Observation
It may be beneficial if electronic prescribing and medicines administration (ePMA) systems were interoperable with electronic patient records (EPR) systems to allow details of medicines omissions to be alerted to staff automatically from the ePMA system to the EPR system.
Observation 2
Observation
It may be beneficial if user menus on electronic prescribing and medicines administration (ePMA) systems provided clear differences and reasoning for the categories used to record medicines omissions.
Observation 3
Observation
It may be beneficial if organisations that use mental health nurses to cover shortages of registered learning disability nurses review their clinical model and conduct a training needs analysis. The aim of this would be to identify skills or training requirements, to make sure mental health nurses have the relevant communication methods and strategies to assist patients with learning disabilities in taking their medication.