It is imperative that individuals in an organisation with a responsibility for medication safety receive communications which highlight known or emerging risks and associated potential mitigation solutions. This will inform the organisational response, drive the medication safety agenda and minimise potential harms related to medicines use.
The organisational response to these communications will require effective collaboration to ensure they are co-ordinated and proportionate.
A organisational governance structure should be in place to ensure medication safety communications are acknowledged and cascaded appropriately. This will provide assurance that the organisation is aware of and managing the identified risks.
Governance structures within an organisation outlining which medication safety communications are reviewed and by whom will ensure critical information is not missed.
A dedicated person such as the Medication Safety Officer (MSO) or a group/committee for example the Medication Safety Committee may take on this role.
Generic MSO email account
All email communication intended for MSOs (or equivalent) will be sent to an organisation’s generic MSO email account; this account needs to be registered with the MHRA by the named MSO when new to post.
A generic email account ensures that time sensitive communications are received in the organisation irrespective of the named MSOs working pattern. The generic MSO mailbox should be set up locally by the organisation’s IT department.
It is the responsibility of the MSO (or equivalent) to ensure notifications and alerts received via the MSO generic email inbox are disseminated and communicated within the organisation appropriately.
The generic MSO email account should be able to be accessed by multiple users to allow business continuity. The responsibility, at any given time, for who is checking the inbox should be clear.
CAS alerts and notifications
The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and other healthcare providers. All relevant communications will be sent by email to the organisation’s generic CAS email inbox.
Organisations should ensure that all medication related CAS communications are forwarded to the generic MSO email address in a timely fashion. Having this requirement in local policies and procedures will support assurance that the MSO (or equivalent) is made aware of all relevant CAS alerts.
There are numerous mechanisms where updates to national practice, guidance or safety messages are disseminated via a network.
The main route of communication between the national network and local MSOs is via the monthly MSO webinar.
The webinar is the primary route for disseminating medication safety updates and information from NHSE, MHRA and the MSO network to MSO’s.
Access to MSO webinar
Email invitations are sent monthly to the generic MSO email account and all members of the local medication safety team can attend. The email will arrive in the days preceding the webinar. The MSO webinar is by invitation only due to the sensitivities of the discussion. Administrators will check the name of all attendees on entry and guests who are not approved or who do not identify themselves at the beginning of the meeting risk being removed. The invitation should not be shared unless agreed in advance via email contact with the national MSO network lead.
SPS Medication Safety Update
The SPS Medicines Advice Team gathers a summary of recent safe medication practice communications, reports and publications and presents this each month at the MSO network webinar.
This resource collates all publications and emerging issues pertinent to medication safety, with the intention of undertaking a ‘do once’ approach in supporting MSOs. It is not all-encompassing however the content is intended to support MSOs in having assurance that they are aware of the most critical updates.
For MSOs unable to attend the MSO network webinar on the day, or for those individuals with an interest in medication safety who wish to view the content, it is available on the SPS website for registered users.
Using the Medication Safety Update effectively provides assurance that an organisation is aware of the most critical medication safety related information, and acts on this to improve safety.
New publications and updates
It is recommended that MSOs (or equivalent) and individuals with an interest in medication safety sign up to the following organisations to receive their medication safety updates and notifications.
The Medicines and Healthcare products Regulatory Agency (MHRA) issues drug safety updates which can be subscribed to. It is possible to create medicines watch lists and sign up for news and alerts from the MHRA through the MHRA Yellow Card app. The app is available to download from the Apple App Store, or Google Play Store
The British National Formulary (BNF) produce a BNF monthly newsletter, summarising the latest guidance and content updates to the BNF and BNF for Children, which can be subscribed to.
Specialist Pharmacy Service
The Specialist Pharmacy Service website provides resources and advice related to medication safety for pharmacists and other professionals using medicines. SPS provides a weekly summary of new and updated content published on the SPS website which can be subscribed to by registering with the SPS website and opting in to receiving communications.
Escalation of safety concerns
Where learning from incident investigation is considered to be of national importance details should be emailed directly to NHS England who will be able to take it through the relevant national policy and strategy systems.
Safety concerns related to a specific medicine product should be escalated to the MHRA. Suspected defective medicines should be reported on the Yellow Card website
The Healthcare Safety Investigation Branch (HSIB) encourages escalation of patient safety concerns from everyone, including patients and their families, the public and NHS staff. Guidance on escalation to HSIB includes what is suitable for referral, how that information is used and how to make contact.
- Medication Safety Observatory changed to new name: Medication Safety Update