This page is part of the wider ‘Aspects of previous patient safety alerts that should inform broader local safety initiatives’ set of webpages.

Staff personal awareness and vigilance

Many past alerts emphasised the importance of personal responsibility for actions to reduce the risk of error; for example, never omitting to administer a medication, always communicating clearly with patients, giving medication on time, ensuring monitoring is in place, always cross-checking before prescribing.

Organisations should adopt system approaches to reducing error in their improvement programmes and patient safety training and education, encompassing personal and professional responsibilities within this, to provide a clear understanding of the limited effectiveness of raising awareness and personally striving to avoid error.

Organisations should prioritise this broader understanding over any specific topic requiring awareness-raising or personal vigilance in past alerts.

Checks before prescribing/dispensing/administering

Specific checks to be undertaken before certain medicines are prescribed or dispensed were highlighted in previous patient alerts, but checks are needed for other medicines as well. For example, previous alerts highlighted the need to check INR or lithium levels are within a safe range before prescribing and dispensing warfarin and lithium respectively, but the need to check clozapine levels is also true in certain clinical situations.

As previous alerts do not provide a comprehensive list, organisations should consider the need to check blood levels and ensure it is safe to prescribe/dispense for a wide range of medications. Other past alerts also advised additional steps in relation to specific medications such as double-checking, using only the 24-hour clock, avoiding interruptions, etc that again are better considered as part of overall processes for improving patient safety than linked to a specific medication.

Go back to the main ‘Aspects of previous patient safety alerts that should inform broader local safety initiatives’ webpage.