The report, which was informed by a review of the evidence on medication errors in England produced by the Policy Research Unit in Economic Evaluation of Health and Care Interventions (EEPRU), makes recommendations for a programme of work to tackle medication error and improve medicine safety and identifies the following fifteen priorities:
- Improved shared decision making so that patients and carers are encouraged to ask
questions about their medications and health and care professionals actively support
patients and carers in making decisions jointly, including when to stop medication.
- Work closely with NHS Digital and others to improve information for patients and families,
and improve access to inpatient medication information.
- Encourage and support patients and families to raise any concerns about their medication.
- Improved shared care between health and care professionals; with increased knowledge
- Professional regulators must ensure adequate training in safe and effective medicines use is embedded in undergraduate training, and professional leadership bodies, working with
professional regulators must ensure continuing professional development adequately
reflects safe and effective medicines use too.
- Professional regulators and professional leadership bodies should also encourage reporting and learning from medication errors.
- Work with industry and MHRA to produce more patient friendly packaging and labelling.
- Work with pharmacy dispensing computer system suppliers to ensure that labelling
contributes to safer use of medicines and does not hinder, for example by labels being stuck over packaging or by using unfamiliar language.
- Build on work to identify and increase awareness of ‘look alike sound alike’ drugs and
develop solutions to prevent these being introduced.
- The accelerated roll-out and optimisation of hospital e-prescribing and medicines
- The roll-out of proven interventions in primary care such as PINCER.
- The development of a prioritised and comprehensive suite of metrics on medication error
aimed at improvement.
- Development of a repository of good practice to share learning.
- New research on medication error should be encouraged and directed down the best
avenue to facilitate positive change.
- A programme on medication safety and error should be established, in line with the domains and early priorities set out by WHO.