The Medicines Safety Improvement Programme

All Medicines Safety Improvement Programme activities are currently being reviewed to support the national COVID-19 response. The key objective is to provide maximum support to frontline colleagues in the NHS and the community.

Non-urgent work (unrelated to COVID-19) is on hold until further notice. Please see further details on the National Patient Safety Improvement Programmes page.

Background to the programme

In 2017, the World Health Organisation (WHO) launched its third Global Patient Safety Challenge ‘Medication Without Harm’, which aims to reduce the global burden of severe and avoidable medication-related harm by 50% over five years.

DHSC commissioned two major reports (published in February 2018) to understand the scale of harm related to medication, and to recommend areas for improvement.

A Short-Life Working Group made recommendations for work across 4 domains, medicines, healthcare professionals, systems and practices, and patients.

The Secretary of State also commissioned research into the ‘Prevalence and Economic Burden of Medication Errors in the NHS in England’ from the Policy Research Unit in Economic Evaluation of Health and Care Interventions (EEPRU).

What the research identified

  • there are an estimated 237 million ‘medication errors’ per year in the NHS in England, with 66 million of these potentially clinically significant
  • ‘definitely avoidable’ adverse drug reactions collectively cost £98.5 million annually, contribute to 1700, and are directly responsible for, approximately 700 deaths per year

About the programme

We have established a national Medicine Safety Programme (MSP) which is gathering opinion about the most important priorities to address, through three lenses:

  • high risk drugs
  • high risk parts of the medicines use process
  • patients with the highest vulnerabilities

All aspects of medication use will be considered — from safe packaging and labelling design; safer prescribing methods — including electronic prescribing; understanding of human-factor error; the use of metrics to drive a reduction in the risk of harm; to changes to administration protocols.

We are also working, with the Department for Health and Social Care and NHS Digital on developing metrics.

The programme is currently supporting the development and implementation of enabling activity, including EPMA, PINCER, metric development, improved shared decision making and shared care, and improved training for health and care professionals in the safe use of medicines.

We continue to work on the recommendations of the Short Life Working Group of Medication Safety. We will report more fully on our progress following the next Board meeting.

We will shortly be consulting about a model for Medicines Safety Assurance across whole systems, by means of a survey. This is part of the programme’s approach to quality improvement to identify and support best practice, which alongside the use of a national set of metrics, will drive demonstrable improvements in patient care.

We are looking for examples of good medicines safety practice to populate a Best Practice Repository, which aims to support all who work in medicines safety solve problems in their practice.

We are also working to ensure the medicines safety programme plays its part in the National Patient Safety Strategy, which is out for consultation.

For further information, please email