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: January 2023
- Medication Safety Update: November 2022
- Medication Safety Update: October 2022
All our medication safety content
All our guidance on antidotes; and safe administration, storage, prescribing and labelling of all medication.
Assessment and secure storage for the self-administration of medicines
Suitable 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
Patients under hospital care should be supported to continue self-administering unless there are good reasons why they are unable to
Duties and responsibilities for the self-administration of medicines
Duties and responsibilities are outlined for both staff and patients during the process of self-administration of medicines (SAM)
Self-administration of medicines
Self-administering medicines in hospital can benefit patients and organisations alike and should be encouraged wherever it is safe to do
Accessing resources for patients on high risk medicines
A number of resources are available to support the safe use of high-risk medicines. Healthcare professionals should ensure they are available for their patients
Establishing alerts for temperature monitoring systems
Systems that alert staff to an excursion allows for a rapid response and will minimise the time the medicine is outside of its recommended storage conditions
Medication Safety in Primary Care: an on the couch conversation
Tony Jamieson, National Clinical Improvement Lead, discussed medication safety issues with primary care pharmacy staff.
Managing the risks associated with rapid over-infusion of parenteral nutrition in babies
There is a risk of severe harm or death if PN is unintentionally infused too rapidly in babies. Healthcare professionals need to ensure safe practice.
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
Differences between metolazone preparations 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
Worked example of assessing the risk of transcribing
Example 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
Various factors affect the risks associated with using transcribing for medicines administration.
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
Off label medicine use under a Patient Group Direction
This article explains the legislation and guidance on the use of PGDs when a medicine is to be used outside its licence ('off label')
Quality Improvement Alert - Cold Chain Management of COVID-19 Vaccines
An SPS quality improvement alert to highlight the requirements for safe and effective cold storage of COVID-19 vaccines
Inclusion of medicines with Risk Minimisation Measures (RMM) in Patient Group Directions
This article reflects MHRA guidance on the use of PGDs for medications which have risk minimisation measures (RMM).
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
Guidance on issuing the Steroid Emergency Card in adults
The NHS England and NHS Improvement national patient safety alert (NatPSA) has specified a number of actions that organisations need to implement.
SPS Advice Note: Interim position statement 3; BD Field Safety Notice (FSN) and intraocular injections (BD and other syringes)
Advice following the issue of the BD Urgent Field Safety Notice MPS-18-1209 regarding the use of BD and BBraun (Medline) syringes for intraocular injections.
Keeping patients safe: Assurance on oxygen demand and capacity
An exemplar presentation from The Mid Yorkshire Hospitals NHS Trust
Homecare prescription management during COVID-19: exemplar risk assessment (National Homecare Medicines Committee)
This is an exemplar risk assessment for homecare prescription management during Covid-19. It highlights the risks associated with all processes involved in generating and transmitting…
Mixing of medicines and Patient Group Directions
This article provides advice on the legal considerations required when considering mixing medicines to be supplied or administered under a PGD
Suitability of BBraun NRFit Lock Syringes with BBraun NRFit Syringe Caps for storage of injectable medicines
The NHS Pharmaceutical Aseptic Services Group published its requirements for the introduction of NRFit neuraxial syringes and caps for the purposes of drug storage on…
Use of off-label or unlicensed products under Human Medicines Regulations 2012 Schedule 17 exemptions
The below summary details the legal position regarding the sale, supply or administration of off-label/unlicensed products under Schedule 17 of the HMR 2012
Multiple Use of Injectable Medicines in Clinical Areas V 02 February 2020
This 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.…
National Homecare Medicines Committee (NHMC) Homecare Risk Assessment
To support organisations in establishing a robust risk assessment process for new homecare medicines services the NHMC has developed a tool for local use. …
Regional Medicines Optimisation Committee Antidotes Advisory Statement
The RMOC recommendation is in the process of being revised to reflect the Royal College of Emergency Medicine (RCEM)/National Poisons Information Service (NPIS) 2021 updated…
Frequently Asked Questions about FMD: (updated January 2019) – NHS provider services and the Falsified Medicines Directive (FMD)
This document supercedes the July 2018 version and includes all FAQs previously published. The deadline for implementation of the EU falsified Medicines Directive is 9th…
Guidance on Handling of Injectable Cytotoxic Drugs in Clinical Areas in in NHS Hospitals in the UK (Yellow Cover) Edition 1 July 2018
Intended audience: This document is intended as a reference and source of information to the following audiences: Nursing staff who handle cytotoxic chemotherapy (Oncology /…
Insulin preparations: RMOC recommendations of safety considerations for formulary decision making
At its meeting on 18th April 2018 the Regional Medicines Optimisation Committee (RMOC) (Midlands and East) reviewed issues pertaining to safety considerations when adopting any…
RMOC Recommendation: Standardising strengths of high risk, unlicensed oral liquids formulations for anti-TB medicines
At the meeting on 26th October 2017 the Regional Medicines Optimisation Committee (North) endorsed the approach put forward by the NHS Pharmaceutical Quality Assurance Committee…
Product Risk Assessment Tools
Product risk assessment tools to support NHS organisations to identify risk resultant from medicinal product presentation.
Generic audit tool: Safe and secure handling of medicines
A generic template is provided to assist the process of auditing safe and secure handling of medicines practices
Guidance for the Purchase and Supply of Unlicensed Medicinal Products Notes for Prescribers and Pharmacists (Yellow Cover)
Recommendations to prescribers and pharmacists involved in the use or procurement of unlicensed medicines and guidance on the assessment of their quality
Positional Statement by the NHSPQA Committee PIC/S Guide to Good Practices for the Preparation of Medicinal Products In Healthcare Establishments 1st edition (Yellow Cover)
The PIC/S ‘Guide to Good Practices for the Preparation of Medicinal Products in Healthcare Establishments’ (PE 010-03) could be used to support the important role…
'Guidelines for the safe and secure handling of medicines' - the 'Duthie' Report
The ‘Guidelines for the Safe and Secure Handling of Medicines’ was a report written by a Joint Subcommittee of the Standing Medical, Nursing and Midwifery,…