These patient safety alerts call on large healthcare provider organisations across a range of healthcare sectors, along with healthcare commissioners, to identify named leaders in both medication and medical device safety roles. These leaders will be supported by two new national networks for medication and medical device safety. The networks will improve communication and feedback on reported safety issues, and enable safer practice to be discussed and shared through webinars, online forums, conferences and workshops.
With respect to the medication safety alert, NHS England and MHRA are working together to simplify and increase reporting, improve data report quality, maximise learning and guide practice to minimise harm from medication errors by:
- sharing incident data between MHRA and NHS England;
- providing new types of feedback from the National Reporting and Learning System (NRLS) and MHRA;
- clarifying medication safety roles and identifying key safety contacts; and,
- setting up a National Medication Safety Network.
The Yellow Card Scheme for reporting suspected adverse drug reactions to the MHRA will continue to operate as normal.
The following actions are identified in the alert (separated by provider):
1. All large healthcare providers including NHS Trusts, community pharmacy multiples, home healthcare companies and those in the independent sector should:
- identify a board level director to have the responsibility to oversee medication error incident reporting and learning;
- identify a Medication Safety Officer (MSO) and email their contact details to the Central Alerting System (CAS) team; and
- identify an existing or new multi-professional group to regularly review medication error incident reports, improve reporting and learning and take local action to improve medication safety.
2. Small healthcare providers including general practices, dental practices, community pharmacies and those in the independent sector should:
- continue to report medication error incidents to the NRLS using the e-form on the NRLS website, or other methods and take action to improve reporting and medication safety locally, supported by medication safety champions in local professional committees, networks, multi-professional groups and commissioners.
3. Healthcare commissioners including Area Teams and Clinical Commissioning Groups are invited to:
- identify a MSO and email their contact details to the CAS team and
- regularly review information from the NRLS and the MHRA to support improvements in reporting and learning and to take local action to improve medication safety.
More detailed information can be found in the supporting information documents for each alert.
The alerts have been issued as stage 3 (directive) alerts. When this stage of alert is issued, organisations will be required to confirm they have implemented specific solutions or actions to mitigate the risk. A checklist will be issued of required actions to be signed-off in a set timeframe.