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 DOACs

30 October 2024Discussion of key current medication safety challenges within healthcare with a focus on the safe use of DOACs; inspiring partnership across the system.

Managing complexities of medication use across care boundaries

26 June 2024Exploring the risks for patients on complex or specialist medicines moving across care boundaries with a focus on strategies to reduce harms

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

21 June 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

Supporting safe use of adrenal crisis emergency management kits

18 November 2024Treatment of adrenal crisis is time critical and relies on timely use of injectable hydrocortisone to prevent harm.

Managing the risk of confusion between injectable penicillin salts

4 October 2024Minimising the risk of confusion between injectable benzylpenicillin salt formulations may prevent harms.

Managing risks associated with oxytocin infusions during labour

24 September 2024Safety strategies can minimise the risk of harms related to oxytocin infusion overdose and delayed therapy.

Using generic liposomal amphotericin B

13 September 2024Learn about differences between generic Amphotericin B Tillomed Liposomal and Amphotericin B Gilead Liposomal, previously branded AmBisome.

Assessing injectables for enteral administration

13 August 2024Clinical decisions on the use of injectable formulations for enteral administration should be guided by safety and practicality.

Managing the risks associated with patients prescribed clozapine

28 June 2024Healthcare professionals in non-specialist services managing patients prescribed clozapine should implement safe practice principles to prevent potential harms.

Clinical considerations for patients prescribed clozapine

28 June 2024Healthcare professionals in all settings who interact with patients prescribed clozapine should be aware of clinical considerations related to its use.

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.
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Other medication safety material

Safer use of Time Critical Medicines

23 October 2024We announce the start of a national scoping review on the safer use of time critical medicines and further resources coming soon.

Understanding when a check adds value to medication processes

11 October 2024Understanding what a check is, the principles of an effective check and factors to consider if introducing an independent second check to a medication process.

Safe management of therapeutic drug monitoring

2 October 2024Organisations must ensure safe management systems are in place to support the management of drugs requiring therapeutic drug monitoring.

Purchasing for safety

19 June 2024Using principles of purchasing for safety when making purchasing decisions supports the safe clinical use of medicines and can minimise inadvertent harm

Investigating suspected tampering with medicines

11 June 2024A systematic approach should be taken to responding to reports of possible malicious tampering, securing the evidence, and seeking specialist advice and support

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 storage of medicines for the self-administration

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

Implementing self-administration of medicines

25 January 2023Individuals receiving healthcare should be supported to continue to self-administer existing/new medications unless there are reasons why they are unable to

Self-administration of medicines

25 January 2023Self-administering medicines in all care settings and at home can benefit both individuals and organisations; it should be encouraged where safely achievable

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.
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