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


A forum for individuals to discuss challenges and successes to inform and inspire medication safety initiatives 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

23 February 2023A 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

Managing the risks of using liquid oral phenobarbital

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

Reversing an adult opioid overdose with naloxone in the medical setting

A patient safety alert highlighted the risks of giving inappropriate doses of naloxone. This page guides on using appropriate intravenous doses.

Using intravenous paracetamol preparations safely in paediatrics

Safety 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

Healthcare 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

Healthcare 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

Potassium 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

Serious 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

Practice points to ensure good governance when planning or designing vaccination services where multiple vaccines are used.

Safe practice for handling multiple COVID-19 vaccines

A number of COVID-19 vaccines are available, all with different handling and dosing requirements; sites need to plan to reduce the risk of errors