Date published: 14 June, 2023
Date last updated: 5 March, 2024
Digital, General practice

Medication safety management

Version 1.1, 14 June 2023

This guidance is part of the Clinical safety section of the Good practice guidelines for GP electronic patient records.

Medication safety management is the effective management of medicines with the aim of reducing risk of error and harm.  Medication includes:

  • any product prescribed by primary, secondary, tertiary, and private healthcare providers
  • any medicinal and herbal products that are available to patients without prescription and that could impact prescribing decisions or interact with other products.

Why medication safety management is important

In line with the NHS Patient Safety Strategy, healthcare providers must be committed to minimising risk and harm to patients and to ensure quality, effective care in the NHS, alongside good patient experience. 

Safety of services is one of the key lines of enquiry by the Care Quality Commission (CQC).

General practice professionals should take steps to ensure that safe prescribing procedures are in place and that patients are fully informed about the medicines they are being prescribed. 

Evidenced based-practice national, local, disease specific, and specialist prescribing guidance should be followed.  There are statutory and professional obligations relating to medicine safety:

Medication safety management can contribute to:

  • medicines optimisation
  • saving lives and reducing harm
  • error reduction
  • less over-prescribing (see National overprescribing review report), reduction in problematic polypharmacy
  • a transparent culture of error/incident reporting
  • improving practice through learning from errors/incidents
  • reducing medicines wastage

Medication safety management in general practice

Clinical responsibilities

All clinicians involved in processing medication should know how to access national and local prescribing guidance, including interactions between medications, such as:

Prescribers must:

Practice responsibilities

Practices should:

  • appoint a prescribing lead
  • have systems in place to ensure the safe management of controlled drugs (as outlined by the CQC)
  • generate electronic scripts using the electronic prescription service (EPS) to ensure higher efficiency, reduction of prescribing errors, e.g., transcription errors, improvement of prescription security, effective prescribing audit, and improved stock control for dispensers
  • optimise the use of various software solutions that help to ensure safe prescribing and allow for prescribing requests, prescribing audits, prescribing optimisation, and monitoring. Software solutions should be compliant with the Data co-ordination board (DCB) requirements
  • ensure that prescribers are trained to use the local software
  • attend any locally (Primary care network, etc.) organised prescribing and medication optimisation meetings
  • undertake prescribing audits to support prescribing practice improvement and personal and practice development
  • be aware of the NHS Digital clinical safety standards relating to health IT software and use.

Patient education and information

Practices should consider informing all patients about the importance of telling their clinicians about any prescribed and non-prescription medication they are taking, as well as any medicinal or herbal products.  This could be done at the time of registration with the practice  or during a consultation.  A patient’s record should be updated accordingly.

Practices should also:

  • consider adding information for patients about this issue on their website such as from me + my medicines, NHS.UK
  • encourage patients to sign up to online access to the services (e.g., using the NHS App) to enable online repeat prescription requests
  • where electronic prescribing is enabled in the clinical system, encourage patients to nominate a pharmacy and use proxy access if appropriate (at the time of registration or when issuing a prescription)
  • consider the needs of patients who have no access to the internet or a smartphone or are unable to use the digital tools and provide appropriate support, to avoid digital exclusion
  • have processes, protocols and competencies in place to ensure safe prescribing for high risk populations, of high risks drugs, and in special circumstances (e.g. end of life)
  • be familiar with the processes to follow if digital systems fail

Record keeping

It’s important to keep patient records up to date and to:

  • keep accurate contemporaneous records of patients’ medication (including over the counter medication, herbal/nutritional products, medication prescribed elsewhere) and allergies
  • promptly address medication change/dosage change requests from secondary care, especially on patients’ discharge from hospital

Repeat prescribing

As well as using EPS for repeat prescribing, practices should:

Do’s

Do:

  • prescribe in line with the national and any local formularies
  • learn from incidents, promoting a culture of honesty and transparency where staff can report incidents both internally, locally and on national incident reporting systems in line with national patient safety strategy
  • use technology to mitigate the risk of errors, including electronic prescribing, medication optimisation software, prescribing audit software monitoring questionnaires and recall systems
  • always check the patient’s record carefully including (but not exclusively) their details, medication history (including over the counter medication, herbal remedies, medication bought over the internet etc.) medical history, allergies/adverse reactions
  • check national and local prescribing guidance
  • use an NHS Smartcard.

Risks and issues

Remote consultations might present a higher risk of prescribing errors.  Specific mitigating guidance ‘High level principles for good practice in remote consultations and prescribing for all healthcare professionals‘ has been issued jointly by multiple registration bodies, including the Royal Pharmaceutical Society.

Other risks include:

  • inadequate monitoring of prescribing (lack of audits, no learning from significant events, lack of open/honest culture in the organisation)
  • inappropriate use of technology and software such as overriding alerts
  • the impact on the practice and prescribers of medicine supply issues.

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Other helpful resources

Date published: 14 June, 2023
Date last updated: 5 March, 2024