Medication safety across the system: time critical medicines

Event 28 June 2023Location Online via WebEx at 12:30-14:00

Discussion of key current medication safety challenges within healthcare with a focus on time critical medicines; inspiring partnership across the system.


28 June 2023


Online via WebEx at 12:30-14:00

About the event

This interactive session was the second of a quarterly series about medication safety aimed at healthcare professionals, working in any sector with a role or passion for medication safety and/or involved in medicines use.

Speakers shared innovative practices that have the potential to be translated and replicated.

Why it’s important

Timely use of medicines are critical and despite efforts to improve safety related to their use, current practice is still leading to patient harm in the NHS. These harms may occur at each stage of the medicines journey and in any setting across the system. This session aimed to equip healthcare professionals with insights, support, and shared learning, to support a reinvigorated approach to improve practice with an aim to minimise these harms.

What was covered

  1. A discussion of key challenges that impact safe use of time critical medicines within the system and why this issue continues to be a challenge for the whole system
  2. ‘Lived experience’ was shared to understand the impact of where time critical medicines are omitted or delayed to inspire actions to improve safety
  3. Shared exemplar practices related to improving the safety with time critical medicines, which will allow for reflection on local practice and consideration for implementation at a local and system level.

Learning Outcomes

  1. Articulate key current challenges related to the safe use of time critical medicines
  2. Use the information shared regarding known harms related to time critical medicines to assess local working practices at both an organisational level and across the system
  3. Reflect on the examples shared and identify actions or responses to recommend locally, in order to improve safe practice
  4. Take opportunities to network with peers to inform the development of appropriate local and system wide responses to time critical medicines concerns

Programme and speakers

System safety spotlight – Time critical medicines

Time Critical Medicines – A time to think differently

An introduction to the spotlight issue exploring whether time critical medicines are as commonly involved in known patient harms since the initial safety alert on ‘reducing harm from omitted and delayed medicines in hospital’. We explore why this continues to be an issue; not just in the acute setting but across the whole system.

Graeme Kirkpatrick

Head of Patient Safety, NHS England

Getting time critical medicines on time – Why it matters

A reflection on why is getting time critical medicines right so important. A healthcare professional shares her lived experience on how the timeliness of medicines administration has  impacted her own Parkinson’s Disease symptom management. Introducing the ten recommendations from the Parkinson’s excellence network and hearing how these can be implemented across the system.

Clare Addison

Lead Nurse for Adult Safeguarding, Surrey and Sussex Healthcare NHS Trust. Co-Lead for South East Parkinson’s Network

Patsy Cotton

Parkinson’s Nurse Specialist, Parkinson’s UK

Sharing of good practice and practical solutions

Innovate workforce solutions to support time critical medicines

Sharing experiences where staff have been upskilled to administer medicines and discussing how this can be translated across all care settings.

Lesley Barnfather

Pharmacy Technician Specialist, Lead WMA project, Northumbria Healthcare NHS Foundation Trust

A self administration journey – How to introduce and embed the principles of self-administration

A shared example of using self-administration principles to minimise harms from time critical medicines. A discussion of challenges and how barriers were overcome. A focus on how this approach could be replicated in any care setting.

Elizabeth McKechnie

Medication Safety Lead Pharmacist, University Hospitals of Leicester NHS Trust

Joanne Gilbertson

Medicines Management Nurse, University Hospitals of Leicester NHS Trust

Promoting patient engagement to support safety with time critical medicines

Exploring the principle of patient engagement as a safety solution. Promoting patient involvement in communication and transfer of information related to time critical medicines across the whole system.

Professor Bryony Dean Franklin

Professor of Medication Safety, UCL School of Pharmacy; Executive Lead Pharmacist, Imperial College Healthcare NHS Trust; Director, NIHR North West London Patient Safety Research Collaboration

Supporting and inspiring medication safety across the system

System safety update

Communication of urgent / topical safety issues and sharing a collection of time critical medicines related resources.

SPS speakers

The meeting will be led by Anna and Emma, with support from Barry and Nicola. You can learn more about our SPS team below.



Information presented in these recordings is correct at time of recording. Current guidance should be followed.

Time Critical Medicines Webinar

Electronic solutions to promote effective communications

Suzanne Cooper shares her experience of using electronic prescribing systems to improve the safe transfer of time critical medication between care settings.

Using the Medicines Supply Tool

Kate Mitchell and Ben Rehman introduce and demonstrate the Medicines Supply Tool which can support healthcare professionals manage supply issues and mitigate against potential harms related to delays of time critical medicine supply. The purpose, origin and maintenance of the tool are presented and potential actions to manage supply issues and shortages are discussed.

A supporting ‘Guide to Managing Medicines Supply and Shortages’ is available from NHSE

A toolkit to promote safe practice

Elizabeth Mckechnie shares her experience with tackling time critical medicine safety in her organisation. Practical examples, which can be translated to work in any care setting, are shared to inspire healthcare professionals to take action towards safety improvements in their care setting and across the system.


We are grateful to our colleagues for recording the following resources related to time critical medicines.

Time critical medicines – What does it mean to the system?

Time critical medicines – What does it mean to medics?

Using the patient medications records to support safe use of time critical medicines

Improving safety of time critical medicines at transfers of care with ambulance service

System Safety Update

Presentation Resources

Contact us

Please contact the Admin Team if you have any questions.