Increased medication incident reporting provides greater opportunities for learning and improving medication safety

Medication Safety Officer (MSO)

A key role of the MSO is to promote and increase medication incident reporting within the organisation to facilitate learning.

The MSO should continually review organisational processes to make reporting easy and to identify and remove barriers where possible.

Ability to report

All healthcare professionals within the organisation require access to the organisational reporting system.  An MSO should have assurance that anyone involved in or informed of a medication incident is aware of how and when to report.


Limited access and poor usability of the system, fear of perceived repercussions to reporting and, failure to feedback outcomes from the report to the reporter are all possible barriers to reporting.


Making access simple may support reporting.  Linking any electronic reporting systems with other systems routinely used may simplify access, for example links from electronic prescribing systems.


Consideration should be given as to whether individuals within the organisation require training on when and how to use the reporting system.

Reducing fear

Staff need reassurance that organisations will endeavour to implement systems solutions rather than focus improvement at an individual staff level.


Providing feedback to reporters on how the incident has been managed and any outcomes from the report gives positive reinforcement and may encourage further reporting.

Supporting staff

Healthcare professionals who are involved in patient safety incidents need to be supported in the period following the incident. The emotional impact of being involved in an incident should not be underestimated. Local occupational health and wellbeing teams should be contacted where necessary.

Just Culture

Promoting a ‘Just Culture’ within an organisation will support staff in feeling confident in reporting incidents without the fear of blame.

A just culture supports consistent, constructive and fair evaluation of actions of staff involved in patient safety incidents. NHSE have a useful guide which details principles that should be considered before formal management action is directed at an individual member of staff.

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