Quality statement 3: Learning from medicines‑related patient safety incidents

Quality statement

Local health and social care providers monitor medicines-related patient safety incidents to inform their learning in the use of medicines.

Rationale

Monitoring medicines-related patient safety incidents can help to identify trends and causes of incidents. Learning from incident reporting and reviewing clinical case notes, and sharing the outcome of learning among local health and social care providers can lead to effective action. This might include setting up computer alerts and delivering continuing professional development. Learning from past incidents can help to minimise the risk of future medicines‑related patient safety incidents and produce better outcomes for people who take medicines.

Quality measures

Structure

a) Evidence of local arrangements to ensure that health and social care providers monitor medicines‑related patient safety incidents.

Data source: Local data collection.

b) Evidence of local arrangements to ensure that health and social care providers report medicines‑related patient safety incidents using national patient safety reporting systems.

Data source: Local data collection, the National Reporting and Learning System, the Yellow Card Scheme.

c) Evidence of local arrangements to ensure that health and social care providers learn from the monitoring and reporting of medicines‑related patient safety incidents.

Data source: Local data collection.

d) Evidence that local health and social care providers have arrangements to share learning about medicines‑related patient safety incidents. This can include feedback on trends or significant incidents to support continuing professional development.

Data source: Local data collection.

Process

Proportion of reported medicines‑related patient safety incidents that are investigated.

Numerator – the number in the denominator that are investigated.

Denominator – the number of reported medicines‑related patient safety incidents.

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, health and social care practitioners, and commissioners

Service providers (such as primary and secondary care, community care and social care) ensure that they have effective systems to monitor and report medicines‑related patient safety incidents, and that they share learning with other local health and social care organisations to ensure the safe use of medicines.

Health and social care practitioners (such as prescribers, community pharmacists, and residential care practitioners) report medicines-related patient safety incidents using national reporting systems, contribute to the local monitoring of medicines‑related patient safety incidents, and contribute to shared learning with other local health and social care organisations.

Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that providers demonstrate monitoring of medicines‑related patient safety incidents and learning from those incidents.

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

People who take medicines are cared for by local health and social care providers who monitor and report patient safety incidents related to medicines. The providers share the information with other local care providers to ensure the safe use of medicines.

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, recommendation 1.1 and expert opinion]

Monitoring medicines‑related patient safety incidents

Monitoring involves organisations having robust and transparent processes in place to identify, report, prioritise, investigate and learn from medicines‑related patient safety incidents, in line with national patient safety reporting systems. This process should then encourage organisational learning.

[Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (2015) NICE guideline NG5, recommendation 1.1.3]