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

Medication Safety Updates

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

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,…