Quality statement 2: Patient involvement in reporting medicines‑related patient safety incidents

Quality statement

People who are prescribed medicines are given an explanation on how to identify and report medicines‑related patient safety incidents.

Rationale

Reporting of, and learning from, medicines‑related patient safety incidents can be more effective when the people who are prescribed medicines are encouraged and empowered to report incidents. People can be told about identifying and reporting medicines‑related patient safety incidents when a prescription is written or dispensed, or when medication is reviewed. Patient involvement can increase the number of incidents reported through better identification, and can aid learning by health and social care practitioners and organisations responsible for medicines optimisation.

Quality measures

Structure

a) Evidence of arrangements to ensure that people who are prescribed medicines have an explanation of how to identify medicines‑related patient safety incidents.

Data source: Local data collection.

b) Evidence of arrangements to ensure that people who are prescribed medicines have an explanation of how to report medicines‑related patient safety incidents.

Data source: Local data collection.

Process

Proportion of new prescriptions of medicines for which patients are given an explanation on how to identify and report medicines‑related patient safety incidents.

Numerator – the number in the denominator for which patients are given an explanation on how to identify and report medicines‑related patient safety incidents.

Denominator – the number of new prescriptions of medicines.

Data source: Local data collection.

Outcome

Harm attributable to errors in medication.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as primary and secondary care and pharmacy services) ensure that people who are prescribed medicines to have an explanation on how to identify and report medicines‑related patient safety incidents.

Healthcare professionals (such as prescribers and community pharmacists) ensure that they explain to people who are prescribed medicines how to identify and report medicines‑related patient safety incidents. Healthcare professionals can do this when a prescription is written or dispensed, or when medication is reviewed.

Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services that explain to people who are prescribed medicines how to identify and report medicines‑related patient safety incidents.

What the quality statement means for patients, service users and carers

People who are prescribed medicines are told what a medicines‑related patient safety incident is, how to identify and report an incident, and who they can ask for help. They can be told this when a prescription is written or dispensed, or when medication is reviewed.

Source guidance

Definitions of terms used in this quality statement

Medicines-related patient safety incidents

Medicines-related patient safety incidents are unintended or unexpected incidents that were specifically related to medicines use, which could have, or did, lead to patient harm. These include:

  • potentially avoidable medicines‑related hospital admissions and re‑admissions

  • prescribing errors

  • dispensing errors

  • administration errors

  • monitoring errors

  • potentially avoidable adverse events

  • missed doses of medicines

  • near misses (a prevented medicines‑related patient safety incident which could have led to patient harm).

Medicines-related patient safety incidents do not include expected medicines side effects.

[Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (2015) NICE guideline NG5, section 1.1 and expert opinion]

Equality and diversity considerations

Healthcare professionals should recognise that people's ability to understand the issue of medicines‑related patient safety incidents may differ, and take this into account in discussions with the person. Some people may need additional support to understand the information being discussed or to express their concerns about a possible medicines‑related patient safety incident, especially if English is not their first language or if they have communication or sensory difficulties. Healthcare professionals should also take into account that some people may not be able to report an incident online due to lack of access to information technology or because they have insufficient knowledge on how to use it.