Raising the profile of medicines safety: Changing practice and sharing learning from medication incidents

David Erskine, Director, London Medicines Information Services, Specialist Pharmacy ServiceExample from COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUSTPublished
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Summary of the example

The Patient Safety Alert: Improving medication error incident and reporting1,2  raised the profile of medicines safety in our Trust (CDDFT). Our evolving programme, focussing on changing practice and sharing learning from medication incidents, aims to improve reporting and learning by ensuring the value of reporting is recognised at individual, team and organisational level.


We acknowledge that there is not a ‘one size fits all’ approach to this – each topic and audience presents different challenges.  Our programme involves identification of medicines safety messages which are communicated via various mechanisms including individual discussion, team huddles, organisational governance reports, bulletins, computer screen savers and adaptable “quick read” templates. We focus on commonly occurring incidents as well as ‘known’ medicine risks, acknowledging that the audience is constantly changing and that individuals may be hearing information for the first time. A consistent message is shared at all levels.


Engagement of frontline and Trust leadership teams has led to;

  • changes in practice
  • a range of medicine safety interventions
  • increased reporting by medical and nursing staff
  • improvements in the quality of incident reporting including the detail of outcomes and actions recorded

Why we think it’s important

Research has shown that where rates of incident reporting are high there is more likely to be a better culture of safety and risk management3. It is recognised that what we do in response to an incident is more important than the process of reporting the incident and that a positive response not only encourages individuals and teams to recognise the value of reporting but, more importantly, results in safer services.


There are several challenges to reporting medication incidents. Whilst some of these challenges may be based on individual perceptions they are nevertheless barriers to reporting and can include:

  • Organisational culture
  • Lack of acknowledgement or feedback
  • Limited evidence of wider learning or change in practice.
  • Poor engagement by practitioners at all levels
  • Challenges with the practicalities of reporting and the time required


Engaging staff and harnessing the benefits of sharing learning ensures reporting is a powerful mechanism for change rather than purely an administrative process. Evidence of incident reporting leading to improvements, encourages and sustains good levels of reporting by staff.

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Aims and objectives of the work

Our aim is to make reporting of medicines safety issues matter within CDDFT.


Objectives of this work were to

  1. Review policies and procedures to ensure reporting systems are focused on improving safety rather than blaming individuals.
  2. Increase acknowledgement and feedback to individuals and teams by promoting recording of details of outcomes and feedback in response to reported incidents.
  3. Ensure shared learning is evident and visible to staff at all levels across organisation by using a variety of mechanisms to tell a consistent story.
  4. Increase visibility of evidence of change in practice by highlighting when implementation of medicine safety interventions is in response to reported medication incidents and identified themes.
  5. Engage with staff at all levels across the organisation so that frontline and senior staff can see how reporting can influence organisational decisions and change practice.
  6. Improve the quality of reported incidents by making it easier to report.

Raise the profile of ‘known’ medicines safety risks with a constantly changing audience to maintain an organisational memory.


1. Initial actions included:
a. Review of the Trust incident management policy.
b. Simplify the process of incident reporting and ensure staff receive immediate acknowledgement of reported incidents
c. Presenting medication incident reports at Safety Committee and publishing medicines’ safety messages as a Trust computer screensaver
d. Developing processes for analysis of medication incidents

2. Strategies subsequently developed focussed on staff engagement and learning at:
a. Organisational Level:
• Integration of a pharmacist / pharmacy technician into,  presentation of a monthly medicines’ safety report at Trust wide governance committees
• Engagement of Trust senior nurse and leadership teams
• Inclusion of a monthly medicines’ safety theme in multiple Trust communications

b. Team Level:
• Highlighting medicines safety issues using tailored messages delivered via departmental safety huddles
• Embedding known medicines safety risks in junior doctor prescribing workshops

c. Individual Level:
• Involvement of professionals affected by incident
• Pharmacist buddy system and prescribing ‘top tips’ for junior doctors

3. Adaptable “quick read” templates developed to support learning include:
• “Did You Know….? Posters” highlighting medicines issues and changes to processes
• “Medicine Safety Bubbles” highlighting context of the incident, impact on patient and promoting good practice
• “Key Medicines Safety Message” collating good practice reminders using ‘ALWAYS’ or ‘NEVER’ format

4. Improvements were assessed by quantitative and qualitative measures including
a. Number of medication incidents reported
b. Reporting by professional group
c. Completion of outcomes section of medication incident reports
d. Provision of feedback to reporters
e. Pharmacist involvement in medicines related investigations
f. Implementation of medicines safety interventions via electronic prescribing system
g. Practitioner engagement with medicines safety issues

Key findings

1. Implementation of  strategies described resulted in improvements in:

Number of incidents reported [1235 in 2017/18 vs. 1119 in 2012/13]

Number of incidents reported by medical and nursing staff [836 (68%) in 2017/18 vs. 548 (49%) in 2012/13]

Percentage of  incidents with a recorded outcome [75% in 2017/18 vs. 43% in  2012/13]

Percentage of incidents where feedback was provided to reporter [70% in 2017/18 vs. 4% in 2012/13]

2. Number of medicines and falls related RCAs with documented pharmacist support:

  • 2013/2014 – 14
  • 2018/2019 – 40

3.  Qualitative Outcomes include

  • Increased engagement with staff across the organisation and awareness of a consistent medicines safety message
  • Evidence of use of “quick read” templates in multiple locations
    1. Positive feedback “Easily recognisable” “Clear message” “User friendly” “Effective tools”
  • Improved clinical and senior team engagement with safe and secure handling of medicines issues.

4. Amendments to the electronic prescribing system include:

  • Improved management of warfarin
  • Critical medicine alerts e.g. desmopressin, clozapine
  • Addition of timings for Parkinson’s medicines
  • Weight check for IV paracetamol
  • Consultant verification for high risk medicines
  • Warnings for valproate pregnancy prevention programme
  • Prompts for IV antibiotic review
  • Checklist for medication patch administration

A possible unintended consequence was a reduction in the number of medication incidents reported by pharmacy staff, however as the total number of reported medication incidents has marginally improved it is possible that medical and nursing colleagues are taking “ownership” of reporting.


  1. CDDFT Incident Management Policy – Appendix 4 Guidance to Support the Management of Medication Related Incidents
  2. Poster – “Sharing Learning from Reported Medication Incidents” displayed at the MSO Conference January 2019
  3. Example “‘Medicines Safety Bubble” – Quinolones and Tendon Damage
  4. Example ‘Did you know….?” Poster – Adult Desmopressin
  5. Example “Key Medicines Safety Message” – Allergies – STOP and CHECK



National guidance, data and publications

  1. NHS Improvement: Patient Safety Alert: Improving medication error incident and reporting March 2014
  2. NHS Improvement: PSA: Improving medication error incident and reporting; supporting information. March 2014
  3. NHS Confed NPSA briefing: Five actions to improve patient safety reporting Reference 1095 Issue date June 2008[no longer available]