Last edited: 31-10-2024
Overview
Medicines are the most common intervention in healthcare but can also cause severe harm if not used appropriately. Medication safety is everyone's responsibility - we need to work together to ensure that we keep our patients safe.
This webpage is aimed at health and care professionals working across all sectors in BNSSG to highlight any national or local medicines safety resources to promote and support safer practice.
To give any feedback, suggestions for content/resources for this webpage or for more information please contact the BNSSG Medicines Optimisation Team: bnssg.medicines-optimisation@nhs.net
BNSSG Medication Safety Officer (MSO) contact emails:
For further information on Medication Safety, and support and guidance resources for Medication Safety Officers (MSOs) please see the Specialist Pharmacy Services (SPS) website.
Datix Concerns Reporting
Datix Concerns Reporting - reporting tool is the way clinicians and staff inform BNSSG Integrated Care Board (ICB) of issues regarding patient care across BNSSG. Datix reporting tool can be accessed via a web link and helps the identification of themes affecting quality or safety of patient care. Themes will be followed up by the quality or medicines optimisation team with providers and any learning will be shared more widely. Provider organisations will also have their own reporting systems.
Medicines in pregnancy, children and lactation
Pregnancy Prevention Programmes:
- Valproate safety support resources can be found here.
- Topiramate safety support resources can be found here.
- Isotretinoin national risk minimisation materials - for more information on the Isotretinoin Pregnancy Prevention Programme and Acne Vulgaris see here.
Medicines in pregnancy, children and lactation - there is a wealth of information for clinicians to use when considering medications prescribed for use in pregnancy, while breast feeding and with children. It isn't always easy to find this information in one place. This website has been shared with permission from Somerset ICB who have put together guidance and links for clinicians to use when making appropriate decisions with their patients. This information and links provided are for guidance, clinical decisions remain the responsibility of the practitioner; the intention is to help prescribers find evidence-based information and does not replace input from appropriate professionals or constitute medical advice for individual patients. (N.B. some of these resources include Somerset specific guidelines as well as those national resources).
Further information on Prescribing in pregnancy and breast feeding can also be found on Remedy.
Medicines For Children
Medicines for Children provides practical and reassuring advice to empower parents/carers to give medicines correctly and with confidence to their children. All of their medicines information is written by practising health professionals, who provide practical advice that complements information in the British National Formulary for Children. Their medicines information covers medicines that are available over the counter, plus pharmacy and prescription-only medicines. Pharmaceutical companies have no editorial say over the content of their medicines information. Health professionals can share their medicines information leaflets with their young patients’ parents and carers.
Yellow Card (MHRA)
Yellow Card (MHRA) - the Yellow Card reporting site is where healthcare professionals as well as patients and the public can report suspected adverse effects to medicines, vaccines, e-cigarettes, medical device events, defective or falsified (fake) products to the Medicines and Healthcare products Regulatory Agency (MHRA) to ensure safe and effective use.
#MedSafetyWeek
#MedSafetyWeek is a social media campaign that takes place annually usually in November and each year there is a different focus or theme to encourage the reporting of suspected side effects.
This year it takes place on 4 to 10 November 2024. The theme will be ‘the importance of using medicines in the right way to prevent side effects, and to report side effects when they do occur’.
In the UK, the focus will be on the importance of reporting suspected adverse reactions to medicines and vaccines but Yellow Card are also encouraging the reporting of suspected problems with medical devices or other healthcare products to the Yellow Card scheme. Healthcare professionals are asked to support the campaign and talk to their patients and colleagues about side effects and how they can report suspected problems to the MHRA Yellow Card scheme.
MHRA Drug Safety Updates
MHRA Drug Safety Updates - this is the monthly newsletter from the Medicines and Healthcare products Regulatory Agency and its independent advisor the Commission on Human Medicines.
MHRA Central Alerting System (CAS alerts)
MHRA Central Alerting System (CAS alerts) - the Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care.
Specialist Pharmacy Services (SPS)
Specialist Pharmacy Services (SPS) - SPS are commissioned and funded by NHSE and their main purpose is to improve the use of medicines. SPS website joins together experts to create a rich source of impartial advice for pharmacists and other professionals using medicines. Healthcare professionals in primary care can now get in touch with SPS for medicines advice using a single contact number (0300 770 8564) and email address (asksps.nhs@sps.direct)
Medication Safety Update - Each month the SPS Medicines Advice team gathers and reviews recent medication safety communications, reports, publications and practice research. The slide deck resource includes items considered pertinent to supporting or delivering against the medication safety agenda.
Items include:
- Medication related safety alerts and notifications
- Summary of Product Characteristics (SPC) changes
- Risk minimisation materials
- Medication shortages and discontinuations
- Publications and reports
- Prevention of Future Death Reports (Regulation 28) recommendations
- Primary research papers on medication safety
SPS Medication Safety Update can be found here.
Care Quality Commission (CQC)
Care Quality Commission (CQC) - The CQC is the independent regulator of health and social care in England. Its role is to register providers and to check, through inspection and ongoing monitoring, that standards are being met. As part of CQCs statutory responsibilities it works to oversee the safer management of controlled drugs. This involves publishing an annual report on controlled drugs and also maintaining a national register of Controlled Drugs Accountable Officer’s (CDAO). Organisations are required to update CQC with any changes to their CDAO arrangements. CQC provide useful resources for adult social care and on many topics related to Medicines Optimisation.
The CQC has information for practices on how to respond to patient safety. GP mythbuster 91: Patient safety alerts
Orange Guidelines
Orange Guidelines - these are the full national guidelines on Opioid Substitution Therapy (OST) initiation and prescribing (UK Clinical Guidelines on Clinical Management of Drug Misuse and Dependence). The following sections are particularly useful for prescribers:
- pharmacological interventions (section 4, pages 83 - 113)
- initiation of methadone /buprenorphine (section 4.4, pages 90 - 100)
- methadone dosing (section 4.4.7, pages 97 - 98)
- buprenorphine dosing (section 4.4.8, pages 99 - 100)
NHS England Controlled Drugs Team
NHS England Controlled Drugs Team - the NHSE Controlled Drugs webpage contains links to resources that will be of use to healthcare professionals who work with controlled drugs.
Controlled Drugs Reporting
Controlled Drugs Reporting - all incidents involving controlled drugs should be reported to the Accountable Officer. This provides assurance that any risks have been mitigated and prompts any action to be taken if they are not. Reporting also allows for the identification of themes in reported incidents from which learning can take place. Clinicians can report incidents online at www.cdreporting.co.uk. Organisations that do have their own Controlled Drugs Accountable Officer are also required to send a summary of concerns relating to controlled drugs in an 'occurrence report' to the accountable officer at NHS England when requested. This information is requested every three months and can be submitted online at www.cdreporting.co.uk. As well as reporting CD incidents via this webpage, any provider can request the destruction of controlled drugs.
Health Innovation West of England
Health Innovation West of England (formerly known as WEAHSN Network) connect the NHS and healthcare innovators, academic organisations, local authorities, charities and industry and provide a range of practical support to facilitate change across health and social care economies, with a clear focus on improving outcomes for patients. As well as delivering national and local programmes that address specific local needs and challenges within their geographies, health innovation networks are also commissioned by NHS England to deliver National Patient Safety Improvement Programmes. There are 15 health innovation networks in England, with our system covered by the West of England. They have created a number of free toolkits and resources to enable the healthcare community and patients to make more informed decisions, understand the most appropriate treatments and manage effective change in their practice. More information about Health Innovation Network West of England can be found here.
World Patient Safety Day 2024
World Patient Safety Day is on 17 September 2024: “Improving diagnosis for patient safety”
World Patient Safety Day is an opportunity to raise public awareness and foster collaboration between patients, health workers, policymakers and health care leaders to improve patient safety.
This year the theme is “Improving diagnosis for patient safety” with the slogan “Get it right, make it safe!”, highlighting the critical importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes. For more information see here.
Health Services Safety Investigations Body (HSSIB)
HSSIB came into operation on 1 October 2023. They are a fully independent arm’s length body of the Department of Health and Social Care. They investigate patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care.
Their investigations aim to reduce patient harm by:
- Supporting the involvement of patients, families and carers in healthcare.
- Supporting healthcare staff to carry out their roles and care for patients safely.
- Creating safer healthcare environments and processes.
- Making healthcare services more efficient.
- Sharing best practice and innovations in patient care.
Reports that HSSIB have published can be found on their website here.
