Medication Safety
Medicines are the most common intervention in healthcare but can also cause severe harm if not used appropriately. All medication errors are potentially avoidable. They can thus be greatly reduced or even prevented by improving the systems and practices of medication, including prescribing, prescription preparation, dispensing, administration and monitoring. Medication safety is everyone's responsibility - we need to work together to ensure that we keep our patients safe.
This webpage is aimed at health and care professionals working across all sectors in BSW to highlight any national or local medicines safety resources to promote and support safer practice.
To give any feedback, suggestions for content for this webpage or for more information please contact the BSW Medicines Optimisation Team: bswicb.prescribing@nhs.net
BSW ICS Medication Safety Officer (MSO) contact emails:
- BSW ICB: bswicb.prescribing@nhs.net
- Royal United Hospital, Bath: ruh-tr.BATHmso@nhs.net
- Great Western Hospital, Swindon: gwhmedsafety@nhs.net
- Salisbury Foundation Trust: sft.mso@nhs.net
Community Service Providers:
- HCRG: alison.dorey@hcrgcaregroup.com
- Wiltshire Health & Care: whc.medicines@nhs.net
- Swindon Community Service: gwhmedsafety@nhs.net
Incident and Adverse Event Reporting
Why it helps to report patient safety events and what happens with reports
Learn from Patient Safety Events (LFPSE) is a centralised system managed by NHS England to record information and offer data and analysis about patient safety events to support safety improvement across all care settings.
All healthcare staff in England, including those working in primary care, are encouraged to use the system to record any events where:
- a patient was harmed, or could have been harmed
- there has been a poor outcome, but it is not yet clear whether an incident contributed or not
- risks to patient safety in the future have been identified
- good care has been delivered that could be learned from to improve patient safety
To record safety events on LFPSE, in most cases primary care staff and organisations without a local risk management system will input information directly via an online account.
To help you request the right type of LFPSE account after registering, the national team has created an additional webpage, listing the key features of each account type and who they are for.
LFPSE has been extensively tested to make it accessible and user-friendly. There is also a national helpdesk to support you with any technical queries around using the online service.
The Care Quality Commission (CQC) GP MythBuster 24 illustrates the important of recording patient safety events, both positive and negative. A positive safety culture encourages staff to be open and honest when things go wrong. Recording patient safety events will proactively improve safety. CQC encourage primary care to adopt the LFPSE service. Further information can be found here: GP mythbuster 24: Recording patient safety events with the Learn from patient safety events (LFPSE) service - Care Quality Commission (cqc.org.uk)
Yellow Card (MHRA) - the Yellow Card reporting site is where healthcare professionals as well as patients and the public can report suspected adverse effects to medicines, vaccines, e-cigarettes, medical device events, defective or falsified (fake) products to the Medicines and Healthcare products Regulatory Agency (MHRA) to ensure safe and effective use.
A useful concise summary for healthcare professionals can be found here
More detail can be found here: Resources | Making medicines and medical devices safer (mhra.gov.uk)
Medicine Safety Updates
MHRA Drug Safety Updates - this is the monthly newsletter from the Medicines and Healthcare products Regulatory Agency and its independent advisor the Commission on Human Medicines.
Monthly Drug Safety Update can be located here: Drug Safety Update: monthly PDF newsletter - GOV.UK (www.gov.uk)
To sign up for updates or to access subscribe preferences, click here: Medicines and Healthcare products Regulatory Agency (govdelivery.com)
There are a range of national bodies and teams that issue safety communications to healthcare providers about risks of serious harm to patients. In the past this has been done through a variety of means such as alerts, messages, and notices. The National Patient Safety Alerting Committee (NaPSAC) has been established to improve the effectiveness of these safety critical communications and to support providers to better implement the required actions. The keyway NaPSAC is doing this is through the introduction of National Patient Safety Alerts.
As outlined in the alert ‘The introduction of National Patient Safety Alerts’, issued in September 2019, providers are required to fundamentally review their systems for implementing the actions required by National Patient Safety Alerts. This includes revising policies, processes and governance systems to meet the management and oversight requirements for the implementation of these alerts. List of NatPSA alerts can be accessed through the Central Alerting System (CAS) here CAS - Search Alert (mhra.gov.uk)
The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts (including NatPSA), important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care.
GP mythbuster 91: Patient safety alert: GP mythbuster 91: Patient safety alerts - Care Quality Commission (cqc.org.uk)
Strategic initiatives
In March 2017, the World Health Organisation launched its global patient safety challenge. 'Medication without harm' aims to reduce severe avoidable medication related harm. The aim is to reduce this harm by 50% globally in the next 5 years.
5 Moments for Medication Safety is a patient engagement tool developed to support the implementation of the third WHO Global Patient Safety Challenge: Medication Without Harm. The tool focuses on 5 key moments where action by the patient or caregiver can reduce the risk of harm associated with the use of medication/s. This tool aims to engage and empower patients to be involved in their own care. It should be used in collaboration with health professionals, but should always remain with the patients, their families or caregivers.
For further information on WHO publication and patient engagement tool can be found here: Medication Without Harm (who.int)
The National Patient Safety Improvement Programmes (SIPs) collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system.
The Medicines Safety Improvement Programme (MedSIP) addresses the most important causes of severe harm associated with medicines, most of which have been known about for years but continue to challenge the health and care systems in England.
The key ambitions for MedSIP are as follows:
- Improving care for people with persistent pain by reducing opioid analgesic use.
- Improving care for people with epilepsy, bipolar and conditions for which Valproate is prescribed.
- Improving care for people taking anticoagulants.
- Developing the Medication Safety Officer workforce.
For further information on local MedSIP programme and guidance resources please see the local AHSN website
Other Resources
Care Quality Commission (CQC) - The CQC is the independent regulator of health and social care in England. Its role is to register providers and to check, through inspection and ongoing monitoring, that standards are being met.
The CQC has developed a suite of clinical searches with Ardens which are now routinely used when carrying out inspections of GP practices. They were designed to focus on areas of clinical importance, reflecting the profession’s agreed shared view of quality and to contribute to a consistent regulatory approach. The majority of the searches focus on safe prescribing, monitoring of higher risk drugs, management of long-term conditions and identification of potential missed diagnoses. They identify cohorts of patients who may require further attention.
CQC Ardens Clinical Searches: https://www.ardens.org.uk/cqc/
How to access the CQC Ardens Searches: https://vimeo.com/705820489/f6eb7bf3d1
They are not intended to be used (nor should they be) as a substitute for a practice’s own governance systems and processes for managing patient care.
Other prescribing monitoring resources available:
GP mythbuster on managing high risk medicine: GP mythbuster 84: Managing high risk medicines in general practice - Care Quality Commission (cqc.org.uk)
Ardens Prescribing Monitoring Report: https://support-ew.ardens.org.uk/support/solutions/articles/31000167685-prescribing-monitoring-searches
Ardens Bath Reporting: https://support.ardens.org.uk/support/solutions/articles/31000134146-batch-reporting
There is a wealth of information on the Somerset ICB website for clinicians to use when considering medications prescribed for use in pregnancy, while breast feeding and with children. It isn't always easy to find this information in one place. Somerset ICB have put together guidance and links for clinicians to use when making appropriate decisions with their patients. This information and links provided are for guidance, clinical decisions remain the responsibility of the practitioner; the intention is to help prescribers find evidence-based information and does not replace input from appropriate professionals or constitute medical advice for individual patients. (N.B. some of these resources include Somerset specific guidelines as well as those national resources).
NHS England Controlled Drugs Team – Resource link: here
the NHSE Controlled Drugs webpage contains links to resources that will be of use to healthcare professionals who work with controlled drugs.
The Southwest controlled drugs team that covers BSW can be easily connected through the generic inbox: england.southwestcontrolleddrugs@nhs.net
Controlled Drugs Reporting - all incidents involving controlled drugs should be reported to the Accountable Officer. This provides assurance that any risks have been mitigated and prompts any action to be taken if they are not. Reporting also allows for the identification of themes in reported incidents from which learning can take place. Clinicians can report incidents online at www.cdreporting.co.uk. Organisations that do have their own Controlled Drugs Accountable Officer are also required to send a summary of concerns relating to controlled drugs in an 'occurrence report' to the accountable officer at NHS England when requested. This information is requested every three months and can be submitted online at www.cdreporting.co.uk. As well as reporting CD incidents via this webpage, any provider can request the destruction of controlled drugs.
Specialist Pharmacy Services (SPS) are commissioned and funded by NHS England, and their main purpose is to improve the use of medicines. SPS website joins together experts to create a rich source of impartial advice for pharmacists and other professionals using medicines. Healthcare professionals in primary care can now get in touch with SPS for medicines advice using a single contact number (0300 770 8564) and email address (asksps.nhs@sps.direct).
The SPS website includes a wealth of resource to support Medication Safety including:
PrescQIPP is an evidence-based resources platform with the mission is to help NHS organisations to improve medicines-related care to patients, through the provision of robust, accessible and evidence-based resources. They also provide a platform to share innovation, learning and good practice.
PrescQIPP Medicines Safety resources include a range of webinars, shared good practice and national tool that can be adapted for local use. The web kit resources can be found here: Medicines Safety | PrescQIPP C.I.C
The Wessex AHSN Medicine Safety Portal resources site aims to help GPs, pharmacists and nurses in primary care to use medicines safely. It contains a range of clinical topics section with e-learning showing how to protect patients from inadvertent harm from selected prescription medicines. Resources to help with problem solving on subjects such as interactions, shortages, and the safety of herbal medicines, and an index to free online information sources about medicines to help with decision-making.
Further information on Wessex AHSN Medicine Safety Portal can also be found here Medicines Safety Portal: Welcome! (medicinesafety.co.uk).
ECLIPSE stands for: Electronic Checking Leading to Improved Prescribing Safety & Efficiency. It is an NHS Digital assured Patient Support Platform that will empower our primary care clinicians to deliver safe and efficient patient care. The platform consists of a range of medicine safety elements such as prescribing safety RADAR alerts, DOAC safety programme, DMARD safety and CQC medicine safety monitoring dashboard.
BSW practices would be able to access the eclipse interface via here