Practical guidance to ensure opportunities to learn from local intelligence, including patient harm are translated into shared local and national learning

Role of the Medication Safety Officer

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

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

Using reporting systems

The review and management of reports provides information of what led to, or had the potential to, cause harm and then provides the opportunity to use the intelligence to prevent future harms.

Each organisation will have specific reporting management systems for different issues, such as incidents, claims, complaints and mortality. Many allow for interrogation and filtering to support individuals with a role in medication safety to focus on reports related to the use of medicines.  An MSO (or equivalent) will need to know and understand these systems to ensure the responsibilities of the role are met.

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.

Not all incidents will require individualised investigation.  Conducting a medication incident investigation may be required in certain circumstances.

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 and NHS Patient Safety workspace on Future NHS.

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

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

For the majority of organisations data from the reporting system will be uploaded on to the national system automatically.  Promoting reporting and ensuring of good quality data within the organisations reporting system will enable learning on the wider national scale.

The NHS is currently in the process of switching over from the National Reporting and Learning System (NRLS) to Learning From Patient Safety Events (LFPSE) and all organisations are expected to have transitioned by March 2023.  Local incident reporting systems will then all automatically feed into LFPSE.

MSO escalation channels

Where the learning is considered to be of national importance then this should be communicated directly to NHSE to ensure the issue 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 for consideration for inclusion in the national MSO webinar.

Learning from deaths

Mortality reviews are undertaken to help understand the care a person received before they died.  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.

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

Shared national learning

Several organisations and independent bodies provide publications which support shared learning.  Individuals with a responsibility for reviewing and subsequent implementation of 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.


The Yellow Card scheme is the MHRA’s system for collecting suspected medication side effects and adverse incidents involving medical devices. This information is collated and swiftly investigated to inform potential safety alerts and notifications.


The Healthcare Safety Investigation Branch (HSIB) 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 recommendations to reduce risk and improve safety.

You can sign up to receive HSIB email alerts

NHS Resolution

NHS Resolution provide expertise to the NHS to understand their own claims risk profiles to target safety activity and share learning across the health service nationwide.

They support shared learning for improvement that arise from claims, concerns and disputes from across the NHS by producing a number of resources highlighting identified high risk areas and providing guidance with potential actions to reduce harm.

Further resources

Resources to support learning from medication incidents and harms

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