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

Prioritising local safety improvement work for medication

Prioritising the allocation of resources is a critical element of any organisation’s planning for patient safety improvement. Resources are most commonly spread across activities intended to:

• maintain patient safety,
• monitor patient safety and
• improve patient safety.

The organisation’s patient safety challenges can be identified using a range of methods and should be informed by national advice and guidance.

Prioritisation of resources should align with the organisation’s risk management strategy, consider priorities set nationally and across the integrated care system, and where possible a collaborative approach should be taken to achieve better outcomes and economies of scale. For example, through engagement with the Medicines Safety Improvement Programme and through engagement with local safety networks.

As part of prioritisation of resources, organisations should consider a range of approaches to patient safety management based upon the level of risk. Low and moderate risks, with adequate controls, might be monitored through audit (either of records or through observation), while higher risks may require quality improvement to develop reliable controls.

High-risk medicines were traditionally defined as medicines that have a high risk of causing injury or harm if they are misused or used in error. Error rates with these medications are not necessarily higher than with any other medicines, but when problems occur, the consequences can be more immediate and significant.

Some past alerts described identifying and implementing ongoing safety improvement work for some specific types of high-risk medications. Some included more generic requirements to identify high-risk medications, and in some cases provided lists of medications that should be considered at high risk of error in calculating loading doses, or considered ‘critical’ or ‘crucial’ in terms of the timeliness of their administration. These past alerts were not intended as a comprehensive list of all high-risk medications.

More recent definitions of high-risk medications include those with potential to cause significant harm even when used entirely correctly, but where healthcare intervention could reduce the risk of harm; for example, the response to an anaphylactic reaction to vaccination is critical in reducing the risk of severe harm or death.

Patient safety research emphasises that improvement work for high-risk medications needs to encompass the entire medication journey; from purchasing, the risk of significant harm from prescription omissions (eg not offering anticoagulant treatment after diagnosis of atrial fibrillation) or administration delay or omission, to the risk from a lack of appropriate monitoring.

Best current practice also encourages thinking beyond the medication type, including consideration of ‘higher risk patients’ (eg those at increased risk of medication-related harm such as neonates and children, people with learning disabilities, older people, and adults of low body weight) and ‘higher risk situations’ (eg transitions between primary and secondary care, urgent response to life-threatening emergencies, isolated working situations).

Research has also identified that preventable deaths due to medication problems in acute hospitals typically relate to the cumulative effect of moderate harm incidents, often in medications not traditionally considered high-risk, rather than single catastrophic errors.

Current improvement approaches often integrate medication-related work into wider challenges; for example, overall fluid balance to reduce the risk of AKI or heart failure, and deprescribing to reduce the risk of falls in care home residents. Safety interventions often need a wider focus than high-risk medication alone; for example, mis-selection of high-risk medications at dispensing or administration stages cannot be considered in isolation, but only in combination with the LASA medications they might be confused with.

Safety improvement efforts will typically be most effective when directed at underlying causes rather than individual medication groups; for example, primary care research suggests significant medication-related harm relates to failure to prescribe and failure to monitor, and “better organisation of key systems (eg referrals, test result management, identifying non-adherence) and related administration could have prevented most incidents”.

Organisations also need to consider the risks remaining after the implementation of safety improvement initiatives, rather than the absolute risks outlined in past alerts. For example, an organisation may find that appropriately implemented EPMA has substantially reduced the risk of omissions in administration of critical medications, but that a focus on medicines reconciliation on transfer from acute care back to primary care is still needed to avoid the risk of omissions in prescribing critical medication.

All organisations will be caring for patient groups with differing medication needs, but the highest risk medications will not be the same for a mental health service, a community rehabilitation hospital, a specialist hospital, a general practice, and a pharmacy chain. Improvement work will also increasingly be driven by cross-organisational priority setting that addresses risks from the perspective of the patient pathway rather than of provider organisations.

Ensuring that efforts are concentrated where there are the best opportunities to reduce the risk of death or severe harm remains a core patient safety principle, but this should be based on a broad range of locally relevant sources and the current literature and clinical guidance rather than on medications listed as high risk in past alerts.

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