Learning from medication safety events

Role of the Medication Safety Officer

The Medication Safety Officer (MSO) is the named individual within an organisation responsible for encouraging medication incident reporting. The MSO must also ensure that this translates into learning that will reduce potential harm from medicines use.

There is opportunity for MSOs to use their expertise to ensure organisational and national learning from all harms, adverse events, complaints and patient and carer engagement. Collaboration is key in supporting this opportunity.

Medication safety events

A medication safety event is a situation that has involved medication where there is potential for learning. It could be an incident where something went wrong and a review of the processes and systems that led to it are needed. It could also be an event where patient care was improved and there is benefit from sharing the learning to replicate elsewhere in the organisation.

Specific examples include:

• incidents that have caused harm
• situations that had the potential to cause harm
• cases where there was significant potential for learning
• intelligence from other reviews for example mortality reviews
• sources such as complaints or patient feedback

Medication incident learning

An MSO has the responsibility to demonstrate effective systems within the organisation to achieve organisational learning from medication incidents.

Every incident that leads to, or has the potential, to cause harm should be reported but not all of them will need to be individually investigated.

Organisations should respond to medication incidents following the NHS England Patient Safety Incident Response Framework.

Thematic analysis

Thematic analysis can be undertaken on specific repeated incidents to identify contributory factors and guide future safety improvement work. There are a number of thematic review templates available with examples provided in the MSO workspace on Future NHS (login required) and NHS Patient Safety workspace on Future NHS (login required).

Where a theme has been identified, establishment of a multidisciplinary group to review these incidents to identify possible safety solutions is recommended. These groups should ensure representation from all relevant clinical specialists, professions and care settings. Consider entering any identified risks onto the organisational risk register.

Learning from deaths

Mortality reviews are undertaken to help understand the care a person received before they died. NHS England National guidance and framework on learning from deaths aims to help standardise and improve how NHS providers report, investigate and learn from deaths.

MSOs may find it useful to be part of the organisational mortality review group (or equivalent) to ensure any medication related learning is shared, common themes and contributory factors are recognised and improvement is aligned.

Learning from patients

There are opportunities for learning in any service provision or scenario which engages with the patient. Examples include patient engagement groups and medicines advice services.

Examples of learning from pharmacy Medicines Advice teams who run patient medicines helplines are available on the MSO workspace on the Future NHS platform.

Escalation for wider learning

An MSO is responsible for ensuring that, where appropriate, learning from local medication incidents is shared to inform wider learning. There are a number of communication routes to escalate medication safety concerns. These will be reviewed by national organisations or independent bodies.

Automated escalation

Local reporting systems automatically feed into NHS England Learning From Patient Safety Events (LFPSE). Promoting reporting and ensuring good quality data within the organisation’s reporting system will enable learning on the wider national scale.

MSO escalation channels

Where the learning is considered to be of national importance then this should be communicated directly to NHS England via email to patientsafety.enquiries@nhs.net to ensure the issue is taken through the relevant national policy and strategy systems for review.

MSO networks

An MSO should consider each local incident and assess whether associated learning could be relevant to other organisations. In these instances, it should be shared at the regional MSO meeting and if appropriate, highlighted to the MSO Network Lead via email to lnwh-tr.sps-mso@nhs.net to consider including in the national MSO webinar.

Shared national learning

Several organisations and independent bodies provide publications which support shared learning. Individuals with a responsibility for reviewing and then implementing medication safety strategies outlined in these publications may benefit from signing up to receive communications.

Where organisations are mandated to take action following national learning, these will be communicated as a patient safety alert or notification.

MHRA

Through the Yellow Card scheme the MHRA collects and monitors information on suspected safety concerns involving healthcare products, such as side effects caused by medicines and adverse incidents involving medical devices. This information is collated and investigated to inform potential safety alerts and notifications.

HSSIB

The Health Services Safety Investigation Branch (HSSIB) conducts independent investigations into patient safety incidents across NHS-funded care in England. The aim of the investigations is to identify contributory factors and make observations and recommendations to reduce risk and improve safety.

You can sign up to receive email alerts via the HSSIB website.

NHS Resolution

NHS Resolution provides national learning materials that can support improvement across the NHS. These materials use real-life claims data, alongside incidents and concerns, to help organisations understand risk, identify system issues and target proactive safety improvement, including learning from medication errors. Materials include reports, films, animations and practical learning materials that can be used locally for training, governance and quality improvement.

Update history