Resources, guidance and support to assess and improve medication safety culture, strategy and policy within the healthcare system

Support and guidance for MSOs

Medication Safety Officers promote and ensure safe medication practice. Our resources provide practical support, guidance and tips for MSOs and those working alongside or managing MSOs as well as any individual responsible for the safe use of medicines.

Understanding the role and responsibilities of the MSO in practice will assist organisations in delivering their medication safety agenda
An infrastructure of support opportunities exists that MSOs should utilise to deliver their role most effectively
Practical guidance on effective collaboration opportunities to promote medication safety improvements
High quality reporting and management of incidents and harms ensures opportunities for learning and improving medication safety
Increased medication incident reporting provides greater opportunities for learning and improving medication safety
Practical guidance to ensure opportunities to learn from local intelligence, including patient harm are translated into shared local and national learning
Organisations should utilise resources to effectively drive improvement based on the learning from incidents, concerns, disputes and claims
Practical guidance to support those undertaking medication incident investigations
Effective communication allows for timely responses to new and emerging medication risks and the sharing of potential safety solutions.
Effective use provides assurance that an organisation is aware of the most critical medication safety related information, and acts on this to improve safety
Healthcare professionals responsible for medication safety in their organisation must deliver an appropriate response to safety alerts
Healthcare professionals delivering the medication safety agenda in their organisation require an understanding of national policy, frameworks and legislation

Events

A forum for individuals to discuss challenges and successes to inform and inspire medication safety initiatives across the system.

MSATS – Safe use of valproate

28 February 2024Discussion of key current medication safety challenges within healthcare with a focus on the safe use of valproate; inspiring partnership across the system

MSATS event: medication safety inequalities

27 September 2023Discussion of key current medication safety challenges within healthcare with a focus on medication inequalities; inspiring partnership across the system.

Medication safety across the system: time critical medicines

28 June 2023Discussion of key current medication safety challenges within healthcare with a focus on time critical medicines; inspiring partnership across the system.

Medication safety across the system: opioid safety

29 March 2023Discussion of key current medication safety challenges within healthcare with a focus on opioids. We aim to inspire partnership working across the system.
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Medication Safety Updates

A summary of recent practice communications reports, publications and safe medication practice research, including emerging issues pertinent to medication safety.

Medication Safety Update

26 March 2024A resource collating the latest medication safety communications and publications to inform, support and inspire medication safety improvements.
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Managing the risks of specific medicines

Identifying known risks associated with specific medications and mitigation strategies to prevent harm

Ensuring time critical use of rasburicase

6 March 2024Timely use of rasburicase for treatment of Tumour Lysis Syndrome is essential. Mitigation strategies can minimise harm associated with delayed therapy.

MSATS – Safe use of valproate

28 February 2024Discussion of key current medication safety challenges within healthcare with a focus on the safe use of valproate; inspiring partnership across the system

Managing the risks of using liquid oral phenobarbital

2 November 2023Minimising the risk of confusion between phenobarbital liquid formulations and awareness of alcohol content may prevent harms.

Accessing resources for patients on high risk medicines

19 December 2022A number of resources are available to support the safe use of high-risk medicines. Healthcare professionals should ensure they are available for their patients

Using intravenous paracetamol preparations safely in paediatrics

21 September 2022Safety risks and mitigation strategies are described to reduce the risk of errors with intravenous paracetamol in neonates, infants, and children.

Safety considerations when using Vitamin D

7 September 2022Healthcare professionals who use vitamin D should be aware of the risks of toxicity and safe practice principles which may prevent patient harm

Metolazone preparation differences and safety considerations

7 September 2022Healthcare professionals involved in the use of metolazone need to be aware of the differences between licensed and unlicensed products to ensure safe care.

Using potassium permanganate for skin conditions or wound care

15 November 2021Potassium permanganate is a chemical product. We review the evidence for using it in wound care and highlight the risk of severe harm associated with wrong use.

Understanding safety risks with betamethasone soluble tablets used as mouthwash

9 July 2021Serious side effects can be caused if betamethasone soluble tablets used as mouthwash are swallowed. Providing clear patient directions can help prevent harm

Good governance guidance when handling multiple COVID-19 vaccines

2 March 2021Practice points to ensure good governance when planning or designing vaccination services where multiple vaccines are used.
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Other medication safety material

Developing Medication Safety Across The System (MSATS)

15 September 2023Medication Safety Across the System (MSATS) provides resources and networking to inspire and equip individuals in promoting the safe use of medicines.

Giving intermittent intravenous infusions by gravity in adults

12 July 2023Infusion by gravity is not the preferred method of administration, but may be necessary in some circumstances. Ensure a risk assessment is undertaken.

Managing the risks of using effervescent tablets in children

9 March 2023Careful use of effervescent or soluble tablets to deliver part tablet doses for children and neonates can minimise risks of toxicity or suboptimal therapy.

Assessment and secure storage for the self-administration of medicines

25 January 2023Suitable medicines must be stored safely and securely in accordance with organisational policy, while still supporting self-administration

Implementation considerations for the self-administration of medicines

25 January 2023Patients under hospital care should be supported to continue self-administering unless there are good reasons why they are unable to

Self-administration of medicines

25 January 2023Self-administering medicines in hospital can benefit patients and organisations alike and should be encouraged wherever it is safe to do

Collaboration opportunities to improve medication safety

15 December 2022Practical guidance on effective collaboration opportunities to promote medication safety improvements

Communication opportunities to improve medication safety

15 December 2022Effective communication allows for timely responses to new and emerging medication risks and the sharing of potential safety solutions.

Responding to medication safety alerts and notifications

15 December 2022Healthcare professionals responsible for medication safety in their organisation must deliver an appropriate response to safety alerts

Reporting and management of medication incidents and harms

15 December 2022High quality reporting and management of incidents and harms ensures opportunities for learning and improving medication safety

Learning from medication incidents and harms

15 December 2022Practical guidance to ensure opportunities to learn from local intelligence, including patient harm are translated into shared local and national learning

Understanding medication safety policy and frameworks

15 December 2022Healthcare professionals delivering the medication safety agenda in their organisation require an understanding of national policy, frameworks and legislation

Using the Medication Safety Update effectively

15 December 2022Effective use provides assurance that an organisation is aware of the most critical medication safety related information, and acts on this to improve safety

Promoting medication incident reporting

15 December 2022Increased medication incident reporting provides greater opportunities for learning and improving medication safety

Conducting a medication incident investigation

15 December 2022Practical guidance to support those undertaking medication incident investigations

Resources to support learning from medication incidents and harms

15 December 2022Organisations should utilise resources to effectively drive improvement based on the learning from incidents, concerns, disputes and claims

Practice support for the Medication Safety Officer (MSO)

15 December 2022An infrastructure of support opportunities exists that MSOs should utilise to deliver their role most effectively

The Medication Safety Officer (MSO) role

15 December 2022Understanding the role and responsibilities of the MSO in practice will assist organisations in delivering their medication safety agenda

Medication Safety

Resources, guidance and support to assess and improve medication safety culture, strategy and policy within the healthcare system

Understanding why temperature management is important for medicines storage

10 November 2022Temperature control and monitoring of storage areas to avoid temperature excursions; ensuring medicines are fit for purpose at administration to patients

Preventing parenteral nutrition rapid over-infusion in babies

28 October 2022There is a risk of severe harm or death if PN is unintentionally infused too rapidly in babies. Healthcare professionals need to ensure safe practice.

Worked example of assessing the risk of transcribing

22 February 2022Example where medicines are prescribed by both the patient’s GP and specialist clinicians, and are administered in a patient’s home.

Risk assessing transcribing for administration

22 February 2022Various factors affect the risks associated with using transcribing for medicines administration.

Managing risk when supplying and administering COVID-19 treatments across the system

20 December 2021Differing models exist for the supply and administration of COVID-19 treatments. We guide through the risks and mitigations associated with each.

Including medicines with Risk Minimisation Measures (RMM) in PGDs

16 March 2021Medicines with RMM may not be suitable for inclusion within Patient Group Directions (PGDs). If used, the RMM must be stated within the PGD.

Multiple Use of Injectable Medicines in Clinical Areas V 02 February 2020

19 December 2019This document is intended for multi-professional clinical practitioners to use as a reference and source of information for the prescribing, reconstituting or administering injectable medicines.…

Guidance on Handling of Injectable Cytotoxic Drugs in Clinical Areas in in NHS Hospitals in the UK (Yellow Cover) Edition 1 July 2018

31 July 2018Intended audience: This document is intended as a reference and source of information to the following audiences: Nursing staff who handle cytotoxic chemotherapy (Oncology /…

Product Risk Assessment Tools

15 March 2016Product risk assessment tools to support NHS organisations to identify risk resultant from medicinal product presentation.
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