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Content ArticleThe massive roll-out of new and repurposed medicines in low-income and middle-income countries (LMICs) highlights the need for more efficient pharmacovigilance systems, including use of digital technologies. This study reports a large pragmatic cluster-randomised controlled trial to assess the effectiveness of the smartphone app Med Safety in improving suspected adverse drug reaction (ADR) reporting by healthcare workers to Uganda's National Pharmacovigilance Centre. Between Aug 11, 2020 and Nov 1, 2022, 367 clusters (healthcare facilities providing dolutegravir-based combination antiretroviral therapy in Uganda) received the allocated intervention (184 in the intervention group and 183 in the control group), with 2464 health-care workers (1211 in the intervention group and 1253 in the control group). In the intervention group, health-care workers received pharmacist-delivered training in Med Safety and traditional ADR reporting methods. The control group received the same training as the intervention group except for Med Safety training. The primary outcome was the cluster-level ADR reporting rate at the end of follow-up (at least 12 months) and was analysed in all sites that received the allocated intervention. Med Safety use was found to increase ADR reporting rates among health-care workers in Uganda, particularly non-serious and dolutegravir-related ADRs. These findings suggest that integrating digital technologies into pharmacovigilance systems could strengthen drug-safety monitoring in Uganda and other LMICs.
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News Article
More pharmacies in England to prescribe medication from autumn
Patient Safety Learning posted a news article in News
More pharmacists in England will be able to prescribe medications as part of an effort to speed up care and ease pressure on GP surgeries and hospitals. As part of the Pharmacy First scheme, pharmacists can currently prescribe medication for a sore throat, earache, sinusitis, shingles, impetigo, infected bites and urinary tract infections. From the autumn, the new £340m investment will see five common ailments added to this list, although it is not yet clear what these will be. The Pharmacy First scheme in England was first launched in 2024, and allows patients to see their pharmacist for advice, over-the-counter treatments and prescription-only medicines. According to the Department of Health and Social Care, more than 3.3 million consultations under the scheme were carried out between March 2025 and February 2026. Health Minister Stephen Kinnock said the government is "making the most of our highly skilled pharmacists, while boosting access to services and giving patients more care right on their doorstep". "Independent prescribing will play a major part in delivering this shift, easing pressures on GPs, cutting unnecessary red tape and helping patients get the right care closer to home," he said. The NPA said that while the deal "points in the right direction", it did not address the "crippling" new costs hitting pharmacies. "We remain concerned that it does very little to close the £2.5bn funding gap that the NHS itself identified a year ago," said NPA chairman Dr Olivier Picard, adding that the expanded scheme was "nowhere near ambitious enough to transform patient access to care, nor make full use of pharmacists' skills". He went on: "We are also concerned that the current funding levels mean that many pharmacies will struggle to take this development forwards, risking its success. Pharmacies cannot sustain yet more loss-making work." Read full story Source: BBC News, 29 May 2026 -
Content ArticleThis Health Services Safety Investigation Body (HSSIB) report examines patient safety in relation to electronic prescribing and medicines administration (ePMA). ePMA is software used to prescribe medication and create a record of the medication: that has been given, or due and not given to a patient. Most people admitted to hospital will receive medication, and most acute hospital trusts in England have ePMA functionality in at least part of their organisations. This report focuses on the procurement process used by acute hospital trusts to purchase new ePMA functionality and/or upgrade their existing ePMA functionality and how patient safety learning about ePMA is identified and shared across the healthcare system. It considers how legal, regulatory, standards and assurance functions apply in relation to ePMA safety. ePMA functionality has been shown to reduce some medication errors. However, the current national mechanisms (legislation, regulation, standards and assurance) for ensuring patient safety in relation to ePMA functionality may not adequately provide staff and healthcare organisations with the assurance that risk and hazard identification process are robust and/or share learning associated with the use of ePMA in an acute hospital setting. Findings There are no core national patient safety standards that inform either the design or procurement of ePMA. This can lead to unwarranted variation in functionality across and between ePMA, other electronic systems, and acute hospital trusts, which may pose challenges for staff when prescribing and administering medication. Current assurance mechanisms do not provide national oversight or enforcement of either manufacturer or healthcare provider compliance with legally mandated standards relating to digital clinical safety and interoperability of digital health technology. The safety risks associated with software such as ePMA are complex and may change rapidly. Legislation, regulation and standards may not keep up with the speed of technological change. Manufacturers must self-assess and report whether their ePMA is compliant with relevant standards for their products to be included on an NHS procurement framework. There is variation in the core safety standards identified by acute hospital trusts when procuring and contracting for ePMA functionality. This leads to trusts identifying safety requirements individually, with limited consistency in the approach taken across trusts. Reliance is placed on acute hospital trusts to determine whether ePMA manufacturers have interpreted the medical device regulations appropriately, and to assure themselves that the trust complies with relevant standards. Some trusts do not have the resources, skills and expertise to do this effectively. Digital safety and patient safety teams at local and national level may work in silos, with limited ability to share information or collaborate on ePMA-related decisions that impact on patient safety. There are challenges with identifying national safety learning relating to ePMA as this is not reliably captured, shared or identified through formal reporting routes. There is ongoing work to improve the NHS reporting system to capture digital-related patient safety incidents. There is a reliance on informal networks for sharing ePMA safety issues which means safety concerns may not always be shared with those who need to be aware. Some ePMA manufacturers, whose ePMA functionality is not registered as a medical device choose to apply equivalent governance and assurance measures as if it is a medical device. This is in addition to complying with the digital clinical safety standard (DCB0129). Acute hospital trusts face challenges prioritising and resourcing procurement decisions for ePMA functionality. This leads to challenges and patient safety issues when ePMA is implemented. Clinical safety officers (CSOs) may not be adequately resourced, meaning they have limited capacity to support in managing clinical risks associated with ePMA. There is variation in how the CSO responsibilities set out in the digital clinical standards are interpreted and implemented by trusts. NHS England is working on plans for a formal curriculum and potential accreditation to improve CSO skills and capabilities. HSSIB makes the following safety recommendations Safety recommendation R/2026/086: HSSIB recommends that the Medicines and Healthcare products Regulatory Agency ensures that: routes for manufacturers and healthcare organisations to engage with them are clear and accessible it reviews and provides further guidance and clarification on when electronic prescribing and medicines administration (ePMA) software should be considered a medical device. This will support how ePMA software can be appropriately classified and regulated to improve patient safety. Safety recommendation R/2026/087: HSSIB recommends that NHS England/Department of Health and Social Care establishes a national framework for core electronic prescribing and medicines administration (ePMA) safety. This will provide a clear set of minimum patient safety requirements, helping to reduce unwarranted variation in the safety of ePMA functionality. Safety recommendation R/2026/088: HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance processes. Safety recommendation R/2026/089: HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to: supporting healthcare providers to access digital clinical safety knowledge, capacity and capability integrating digital clinical safety and patient safety, including the associated terminology supporting robust assurance of whether electronic prescribing and medicines administration (ePMA) manufacturers comply with relevant standards in order to be considered for inclusion on an NHS procurement framework. This will support effective decision making and oversight by acute hospital trusts and reduce unwarranted variation in the understanding of, and approach to, adopting ePMA. Safety recommendation R/2026/090: HSSIB recommends that the Care Quality Commission reviews the sector-level assessment frameworks it is developing to include assurance of ongoing compliance with the digital clinical safety standard (DCB0160) for electronic prescribing and medicines administration (ePMA) software. This will help to ensure oversight of ePMA functionality to improve patient safety. HSSIB makes the following safety observations Safety observation O/2026/086: Commercial manufacturers can improve patient safety by applying the standards and expectations for a medical device when developing electronic prescribing and medicines administration (ePMA) functionality, to help provide further assurance to acute hospital trusts procuring or updating ePMA functionality. Safety observation O/2026/087: Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums. Safety observation O/2026/088: Commercial manufacturers and NHS organisations can improve patient safety by contributing to and engaging with ePRaSE (ePrescribing Risk and Safety Evaluation) processes to support ongoing improvement and optimisation of electronic prescribing and medicines administration (ePMA) functionality across the NHS.
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News ArticleCalcium and vitamin D supplements are ineffective at preventing falls and fractures in older people, a review has concluded. Despite their common prescription on the NHS for those at risk of osteoporosis or fracture, and widespread public use for bone health, the comprehensive study found no evidence to support their regular intake specifically for this preventative measure. Published in the British Medical Journal, the research, led by academics in Quebec, Canada, meticulously analysed 69 clinical trials encompassing 153,902 individuals. Their investigation delved into the risk of any fracture, hip fractures, bone breaks occurring outside the spine, spinal fractures, and the overall frequency of falls. The results showed that there was “little to no effect” on the risk of any fracture from taking calcium supplements, vitamin D supplements or both of them combined. The team said almost a third of people aged 65 and over experience at least one fall every year. “As much as 85% of older adults have a fear of falling because of a fall, contributing to reduced daily functioning and increased risk of subsequent falls,” they added. “Furthermore, half of women and one fifth of men will sustain a low trauma fracture during their lifetime, often due to a fall.” They acknowledged some of the trials were small and had few people, and said the results may not apply to people with specific bone disorders or to those receiving drug treatment for osteoporosis. However, they concluded their findings “do not support routine supplementation with calcium or vitamin D, or combined supplementation to prevent fractures and falls” and they suggested doctors, guideline panels and regulatory agencies “should re-evaluate their general recommendations for calcium and vitamin D supplementation in light of current evidence.” Read full story Source: The Independent, 20 May 2026
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Content ArticleUpdated polypharmacy prescribing guidance. 'Appropriate Prescribing - Making medicines safe, effective and sustainable 2025-2028' aims to further improve the care of individuals taking multiple medicines through the use of 7-Steps medicine reviews and promotes a holistic approach to person-centred care.
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Content Article
When safety does not sell (HSJ, 16 February 2026)
Patient Safety Learning posted an article in Medication
In the past month, three things happened that should not be read separately. Imperial College published its latest Global State of Patient Safety report, a coroner issued another report into the preventable death of a child following a medication error, and The Guardian reported that, despite 24 years of warnings, medical negligence in England continues at scale, costing billions and harming thousands of patients each year. Together, they expose an uncomfortable truth: we have become very good at talking about safety, but far less good at changing the conditions that allow predictable harm to persist. -
Content Article
Medicines security—a national priority (4 February 2026)
Patient Safety Learning posted an article in Medication
This report from the House of Lords Public Services Committee finds that medicine supply shortages are not prioritised as the potential national security issue that they represent given the significant risk to people’s health when they cannot access necessary medication. In addition, the UK government and the NHS are key to ensuring patients get the medicines they need, but there is a lack of oversight and coordination over medicine resilience. Reports of medicines shortages are rising. Without access to the right medication, patients may experience worsening health outcomes, stress, and anxiety over their health, and they may fall out of work. In the worst cases, medicines shortages have led to patient deaths. In 2025, 73% of pharmacy team members stated medicine supply issues were putting patient health at risk. Yet despite the significant impact medicines shortages can have, the Department of Health and Social Care (DHSC) were unable to tell us if the number of shortages was rising or falling. Shortages can vary in length and cause–there may be brief interruptions to supply which are swiftly rectified, longer term supply chain disruptions caused by global issues, or complete severance of supply where a medicine is no longer available to the UK. This report sets out the need for clear, proactive leadership from the UK Government to strengthen medicines supply and resilience of supply chains. This leadership needs three strands. Firstly, the DHSC need to better support pharmacies and hospitals to manage shortages. Connectivity presents a key issue here. Currently, community pharmacies and hospitals may only discover a medicine shortage is occurring when they are unable to order medicines for patients, and shortages create extra pressure and work for clinicians trying to support patients, both through sourcing medicines and providing alternatives. The Government needs to improve how it shares information with care providers about shortages and availability of medicine throughout the supply chain, and ensure GPs, hospitals and community pharmacies have the tools they need to access medicines and support patients during shortages. Secondly, the Government needs to better work with the pharmaceutical industry to identify and prevent shortages, through boosting medicines manufacturing and supply chain resilience both globally and once medicines have arrived on UK shores. The Government should clearly signal the importance of stable supply chains to the industry through resilience-focused procurement and contract management. As part of this, the Government should identify and share which medicines they believe are critical for the UK through publishing a Critical Medicines List. The Government should then set out how it plans to boost resilience for medicines on that list. Thirdly, the importance of medicine supply must also be emphasised within government. The impact of medicines shortages goes far beyond the health system, and this should be recognised through more effective cross-government work and putting medicine supply shortages on the National Risk Register. Crucially, this cross-government work must include foreign and trade policy. Problems in medicine supply are not unique to the UK, and governments across the world are taking steps to boost their own medicines resilience. The UK needs to work with international partners to develop a diverse range of medicine resilience measures to make sure the UK is not left behind as other countries shore up their medicine supply. Related reading on the hub: Creon shortages: “It’s just another thing patients with cystic fibrosis could do without” Medication supply issues: Mast cell activation syndrome (MCAS) Medication supply issues: A pharmacist’s perspective Medicines shortages: minimising the impact on patients -
Content Article
“When the medicine no longer works, the patient suffers twice: first from the illness, then from the cost, fear, and uncertainty that follows.” Across Uganda, patients are increasingly experiencing infections that no longer respond to commonly used antibiotics. Conditions that were once easily treatable now require longer hospital stays, repeated courses of treatment and higher out-of-pocket expenditure. These lived experiences reflect the human impact of antimicrobial resistance (AMR), a growing threat to patient safety, equity and health system resilience.[1] Although antimicrobial stewardship (AMS) has traditionally focused on prescribers, laboratories and health facilities, evidence from Uganda demonstrates a critical reality: a large proportion of antibiotic use occurs at community and household level.[2] Without engaging patients and communities as partners, stewardship efforts remain incomplete and unsustainable. Annet Naguudi, Regina Kamoga and Joshua Wamboga from the Uganda Alliance of Patients’ Organizations (UAPO) argue that strengthening AMS in Uganda requires placing patients at the centre of the response and highlights the strategic positioning of the UAPO to lead this shift in line with national and global priorities. The AMR challenge in Uganda: More than a technical problem Uganda is experiencing increasing resistance to widely used antibiotics, including amoxicillin, ciprofloxacin, ceftriaxone, gentamicin and cotrimoxazole.[2][3] Surveillance and hospital-based studies show a rising prevalence of multidrug-resistant organisms, particularly extended-spectrum β-lactamase (ESBL)–producing Enterobacterales and methicillin-resistant Staphylococcus aureus (MRSA).[2] Drug resistance has also been documented across priority disease programmes. Uganda’s first national tuberculosis (TB) drug-resistance survey reported resistance to any first-line anti-TB drug in 10.3% of new patients and 25.9% of previously treated patients, with multidrug-resistant TB reaching 12.1% among the latter group.[4] In malaria, resistance to chloroquine and later sulfadoxine-pyrimethamine emerged in the 1990s and early 2000s, prompting successive changes in national treatment policy toward artemisinin-based combination therapies.[5] HIV drug resistance has similarly increased over time, particularly to non-nucleoside reverse transcriptase inhibitors, contributing to Uganda’s transition to dolutegravir-based first-line regimens with a higher barrier to resistance.[6][7] Together, these trends highlight AMR as a cross-cutting threat requiring coordinated AMS across human health programmes. For patients, AMR translates into: Delayed recovery and treatment failure. Prolonged hospital admissions. Increased healthcare and household costs. Reduced trust in health services. These outcomes are not driven by clinical factors alone. Patient behaviour and community norms, including self-medication, incomplete adherence to treatment, pressure on clinicians to prescribe antibiotics and sharing of medicines within households, are major contributors to inappropriate antimicrobial use in Uganda.[1][8] Addressing this is therefore essential to effective AMS. Strong policy commitment, persistent implementation gaps Uganda has demonstrated strong political commitment to addressing AMR through the National Action Plan on Antimicrobial Resistance II (NAP-AMR II) 2024/25– 2028/29, which aligns with the WHO Global Action Plan on AMR and adopts a One Health approach spanning human, animal and environmental health.[1][8] Key achievements include: Establishment of a national AMR Secretariat. Adoption of the WHO Access, Watch, and Reserve (AWaRe) antibiotic classification. Piloting of AMS committees in selected regional referral hospitals. Annual national AMR awareness campaigns. However, despite these advances, AMS implementation remains uneven. Stewardship activities are largely concentrated in tertiary facilities, diagnostic capacity is limited in many settings, and surveillance systems do not adequately capture community-level antimicrobial use.[8] Critically, patient engagement is not yet systematically embedded within AMS implementation, limiting the reach and sustainability of national efforts. Why patient engagement is central to AMS AMS is most effective when patients are not passive recipients of instructions but active partners in care. Patients influence antimicrobial use at every stage: care-seeking behaviour, expectations during clinical encounters, adherence to prescribed treatment and medicine use within households.[1] Meaningful patient-centred AMS ensures that patients are: Informed, with clear and accessible information about when antibiotics are needed. Empowered, able to ask questions and participate in shared decision-making. Engaged, involved in shaping stewardship messages and interventions. Partners in accountability, reinforcing appropriate use within families and communities. Evidence increasingly shows that stewardship interventions incorporating patient education and community engagement achieve more durable behaviour change than provider-only approaches.[9] The strategic role of patient organisations Patient organisations occupy a unique position within health systems. Rooted in lived experience and trusted by communities, they can translate complex technical guidance into culturally relevant messages, strengthen trust and support accountability for quality and safety. UAPO is a national umbrella body representing 18 patient organisations across diverse disease areas. UAPO provides a unified, patient-centred platform that aligns closely with Uganda’s AMR priorities, particularly in: Rational medicine use. Community awareness and behaviour change. Patient safety and quality of care. Accountability and transparency in health systems. UAPO does not replace government leadership or clinical stewardship. Rather, it complements national and facility-based AMS efforts by anchoring stewardship in lived experience and community practice, consistent with WHO guidance on meaningful patient engagement.[10] Demonstrated patient-led innovation: The CHAIN experience A compelling example of patient-centred AMS in practice is provided by Community Health and Information Network (CHAIN), a UAPO member organisation. CHAIN has developed an innovative gamification-based approach to antimicrobial stewardship education that targets children as agents of change. Through interactive play, storytelling and peer learning, children are taught: When antibiotics are needed—and when they are not. The importance of correct dosing and completing treatment. Hand hygiene and infection prevention. The risks of sharing or misusing medicines. To date, this approach has reached over 20,000 children in rural and urban communities and has demonstrated measurable improvements in hygiene and medicine safety behaviours (UAPO internal programme data). Children trained through the programme act as AMR champions, influencing parents and caregivers and reinforcing responsible antimicrobial use at household and community levels. This early-life intervention addresses AMR at its behavioural roots and complements facility-based stewardship and regulatory interventions.[8] UAPO’s positioning to lead a national patient-centred AMS campaign UAPO is uniquely positioned to lead a national campaign on strengthening AMS through patient engagement by offering: National convening power to bring together patients, clinicians, policymakers, regulators, and partners. Trusted community reach through established patient networks. Strong alignment with national policy, particularly NAP-AMR II. Scalable community-based models that complement technical AMS interventions. A sustainability focus, embedding stewardship behaviours early and across generations. Through this role, UAPO can help ensure that AMS is not only implemented, but understood, owned and sustained by the communities it serves, reinforcing national AMR objectives.[8] Conclusion: From policy to people Uganda has laid strong foundations for addressing antimicrobial resistance through robust policies and multi-sectoral coordination. However, the next phase of progress depends on translating policy and technical guidance into everyday decisions made by patients and families. Strengthening antimicrobial stewardship without engaging patients risks short-lived gains. By placing patients at the centre of AMS and by supporting patient organisations, such as UAPO as partners and conveners, Uganda has an opportunity to demonstrate how meaningful patient engagement can accelerate stewardship, protect life-saving medicines and strengthen health system resilience. Investing in patient-centred AMS is not optional; it is essential. References World Health Organization. Global action plan on antimicrobial resistance, 2015. Okiror JJ, Aruhomukama D, Kajumbula H. Kateete DP. Trends in antimicrobial resistance from sentinel surveillance sites in Uganda. BMC Infectious Diseases 2024; 24: Article 912. Ndugga P, Mboowa G, Karamagi C, Taremwa IM. Antimicrobial resistance patterns among priority bacterial pathogens in Uganda. BMC Infectious Diseases 2024; 24: Article 930. https://doi.org/10.1186/s12879-024- 09806-y. Lukoye D, Adatu F, Musisi K, et al. Anti-tuberculosis drug resistance among new and previously treated sputum smear-positive tuberculosis patients in Uganda: Results of the first national survey. PLoS ONE, 2023; 8(8): e70763. https://doi.org/10.1371/journal.pone.0070763. Kamya MR, Bakyaita NN, Talisuna AO, et al. Increasing antimalarial drug resistance in Uganda and revision of treatment guidelines. The Lancet 2002; 360(9341): 451–2. https://doi.org/10.1016/S0140-6736(02)09609-7. WHO. HIV drug resistance report 2019. World Health Organization, 2019. Wittkop L, Günthard HF, de Wolf F, et al, WHO HIVResNet. Effect of transmitted drug resistance on virological and immunological response to initial combination antiretroviral therapy for HIV. The Lancet HIV 2021; 8(3): e167–e77. https://doi.org/10.1016/S2352-3018(20)30338-7. Ministry of Health (MoH), Republic of Uganda. National Action Plan on Antimicrobial Resistance II (2024/25–2028/29). Government of Uganda, 2025. WHO. Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: A WHO practical toolkit. World Health Organization, 2019. WHO. Framework on integrated, people-centred health services. World Health Organization, 2016. Further reading on the hub: Why won’t my doctor give me antibiotics? Ron Daniels explains My involvement with the Commonwealth Partnerships for Antimicrobial Stewardship Scheme (CwPAMS) in Zambia Top picks: Key resources on antimicrobial resistance Do you have insights to share around patient safety? We would love to hear from other countries and organisations on the work they are doing. Are you a member of the hub? Why not join our global community today (it’s free and easy to sign up) and submit an article or share a resource? You can also contact the editorial team at [email protected]. -
Content ArticleOver one million patients in England rely on time critical medicines that must be taken on time, every time. The consequences of delays can be severe. Research from Parkinson's UK found that for every 17 people who experience problems getting their time critical medicines on time, one patient will die as a result. Delays also increase hospital stays by an average of four days. To help address this challenge, three new web resources have been published as part of the Time Critical Medicines Safety Improvement. These are designed to support hospitals wanting to improve the reliability of medicines administration and will be particularly useful for any Trust that has identified medicines administration as a priority within their Patient Safety Incident Response Plan. Improving the safe use of time critical medicines Understanding time critical medicines to support improvement Defining time critical medicines
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Content ArticleMedication errors remain a major challenge in paediatric prescribing owing to the complexities of weight-based dosing, age-specific formulations and the need for precise calculations. This study examines the association of an indication-based, patient-specific prescribing tool with prescribing errors in paediatric emergency and inpatient settings. Findings suggest that use of the intervention is associated with significantly lower odds of a prescribing error occurring in paediatric settings. Future work should focus on optimising prescriber adherence, enhancing system integration into clinical workflows and exploring economic and user-experience outcomes to maximise impact.
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News ArticleDementia patients in the U.S. are still being prescribed risky stimulant medications despite longstanding warnings about their safety, new research has found. For decades, clinical guidelines have discouraged giving central nervous system stimulants to older patients because they increase the risk of delirium, falls, and hospitalizations. But in a peer-reviewed study published Monday in the American Medical Association's official journal, researchers estimated that roughly 25% of dementia patients enrolled in Medicare parts A, B, and D received at least one such "potentially inappropriate" medication between 2013 and 2021. That description covers a wide range of drugs, including antipsychotics, barbiturates, benzodiazepines, and certain antidepressants such as doxepin and imipramine. Across all study participants, prescriptions fell over the course of the study from around 20% to around 16%, but continued to be higher for patients with cognitive impairment as of 2021. "While this decline was encouraging, over two-thirds of patients receiving these prescriptions lacked a documented clinical indication in 2021, the end of the study period, suggesting high levels of potentially inappropriate and harmful prescribing," said study author and UCLA medicine professor Dr. John M. Mafi. “Compared with patients with normal cognition, we also found higher levels of prescribing among older adults with cognitive impairment, who face a higher risk of adverse effects from these drugs. "These results underscore substantial opportunities to improve the quality and safety of care for millions of older Americans." Read full story Source: The Independent, 13 January 2026
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Content Article
Specialist Pharmacy Service
Patient_Safety_Learning posted an article in Community pharmacies
The Specialist Pharmacy Service (SPS) are a team of pharmacy professionals and support staff, commissioned by NHS England, to provide advice and guidance on Medicines Optimisation. They deliver direct benefits to patients and teams across the NHS. -
Content Article
Podcast: NHS Specialist Pharmacy Service
Patient_Safety_Learning posted an article in Community pharmacies
NHS Specialist Pharmacy Service serves healthcare professionals across the NHS who are involved in all aspects of buying, making and using medicines. They publish regular podcast episodes, all of which can be found via the link below. -
Content ArticleThis national patient safety alert has been issued by the NHS England National Patient Safety team. This alert is for action by acute, community and mental health providers, health and justice services, primary care including nursing and care homes, general practice and community pharmacy. All actions should be completed as soon as possible but no later than 20 November 2026. This alert has been issued in response to concerns of patients with penicillin allergies being incorrectly recorded as a penicillamine allergies in electronic prescribing systems. This creates a risk of a patient with a known penicillin allergy being administered a penicillin-based antibiotic and having a potentially fatal anaphylactic reaction. The risk of this error is not specific to any one electronic prescribing system. Actions required At health system level Primary and secondary care organisations should form a working group across an appropriate geographical area, chaired by an appropriate chief clinical information officer, to co-ordinate implementation of the following actions: Identify patients recorded as having a penicillamine allergy by running a report in relevant digital systems in primary and secondary care. Clinically review the accuracy of the allergy status and amend accordingly. Ensure allergy records in electronic prescribing and related digital systems that record allergy status are updated. To prevent reoccurrence: Secondary care organisations should ensure allergy guidance and training cover safe recording of allergy status in electronic prescribing systems and related digital healthcare systems, including the need to check and correct allergy status on admission and discharge. Primary care should implement additional checks when staff (especially non-clinical staff) input allergy status into GP systems, for example, consider the need for a clinical review if penicillamine is the stated allergen. All organisations should work with digital system suppliers and user groups to develop and deploy additional built-in mitigations to reduce the likelihood of inadvertent recording of the wrong allergy, such as adding alerts and modifying search terms. Organisations should prioritise the safe deployment of upgrades to their digital systems where suppliers have developed effective mitigations and safety features. The working group should strongly consider producing regular reports on allergy status until assurance has been gained that the issue is resolved.
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Content Article
At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. To mark World Antimicrobial Awareness Week, which takes place every year in November, we’ve selected 18 resources related to antimicrobial resistance. Shared with us by hub members and patient safety advocates, they provide valuable insights and practical guidance about AMR. 1 Global antibiotic resistance surveillance report 2025 Antimicrobial resistance (AMR) is a growing threat to global health, undermining the effectiveness of life-saving treatments and placing populations at heightened risk, whether from common infections or routine medical interventions. This new World Health Organization (WHO) report presents a global analysis of antibiotic resistance prevalence and trends, drawing on more than 23 million bacteriologically confirmed cases of bloodstream infections, urinary tract infections, gastrointestinal infections, and urogenital gonorrhoea. 2 Short-term intermittent IV antibiotics – Understanding the issue of under delivery In this blog, Claire Davies, Clinical Therapy Manager at B. Braun Medical Ltd., explores the issue of under delivery and provides essential insights for clinicians to optimise their antibiotic therapy. 3 Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT In this video interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT. 4 Tackling antimicrobial resistance: How to keep antibiotics working for the next century The first WISH report on antimicrobial resistance, 'Antimicrobial Resistance: In search of a collaborative solution', was published in 2013. This report takes stock of what has emerged from the United Nations (UN) General Assembly High-Level Meeting on tackling AMR and makes six recommendations. 5 Silent Pandemic – The global fight against antimicrobial resistance (film) The film Silent Pandemic shows how countries, scientists and private initiatives around the world are networking and forming alliances, and what strategies and measures they are using to counter the advance of antibiotic resistance. 6 Why won’t my doctor give me antibiotics? Ron Daniels explains Ron Daniels, a Consultant in Critical Care, Vice President of the Global Sepsis Alliance and Chief Medical Officer of the United Kingdom Sepsis Trust, explains why doctors have to carefully manage the use of antibiotics in order to protect patients, now and in the future. 7 My involvement with Commonwealth Partnerships for Antimicrobial Stewardship Scheme (CwPAMS) in Zambia In this blog, Fiona Rees, who worked in the NHS as a hospital pharmacist for 13 years, shares her experience of working with colleagues in Zambia to improve the use of antimicrobials by using the expertise of pharmacists to help tackle AMR. 8 Reform - Powering the UK's approach to AMR: the future of AMR policy This report draws on the expert input of a roundtable held by public service think tank Reform in October 2022, to assess progress made against proposals published by Reform in 2020. It recommends actions for NHS England, the Department of Health and Social Care (DHSC) and public health departments to address the threat of AMR. 9 Antimicrobial resistance survivors: calling the world to action This Lancet article was written by a group of AMR survivors and their caregivers in order to share individual stories and perspectives on the impact of AMR. The authors highlight challenges in raising the profile of AMR, including insufficient funding, research, motivation and knowledge. They also call for meaningful patient engagement in the AMR agenda. 10 WHO: How vaccines can help prevent antibiotic resistance – Zimbabwe’s response to drug resistant outbreaks of typhoid and cholera This case study focuses on large outbreaks of antibiotic resistant strains of both cholera and typhoid in Zimbabwe and the steps taken to tackle them. It looks at a mass typhoid Vi-conjugate vaccine (TCV) vaccination campaign from February to March 2019 in nine suburbs of Harare that were severely affected by the outbreaks. 11 British Society for Antimicrobial Chemotherapy: Antimicrobial stewardship: From principles to practice This e-book provides an extensive overview of the day-to-day challenges posed by AMR, tools for setting up stewardship programmes and guidance on how to make the most of existing programmes. Its resources apply the principles of antimicrobial stewardship to a wide range of professions, populations and clinical/care settings. 12 How antibiotic underdosing affected my mum’s end of life care: An interview with Ashleigh Hughes In this interview, senior sister Ashleigh Hughes shares her personal story about the impact of antibiotic underdosing on her Mum’s end of life care. Antibiotic underdosing is a medication safety issue that has profound implications for the health service as well as individual patients, but there is currently a lack of understanding and recognition of the issue. 13 Strengthening primary health care-oriented health systems to address antimicrobial resistance: policy brief WHO policy brief on antimicrobial resistance with an emphasis on primary care. It is noted that ‘Most patient interactions occur in primary care and in the community, where an estimated 80–90% of antibiotics are prescribed. Effective primary care plays a vital role in improving the management of infectious diseases and in reducing overuse and inappropriate use of antibiotics, thus slowing the emergence of antimicrobial resistance (AMR) and ensuring the continued effectiveness of antimicrobials.’ 14 Reducing hospitalizations and multidrug-resistant organisms via regional decolonisation in hospitals and nursing homes Infections due to multidrug-resistant organisms (MDROs) are associated with increased morbidity, mortality, length of hospitalisation, and health care costs. Regional interventions may be advantageous in mitigating MDROs and associated infections. This study evaluated whether implementation of a decolonisation collaborative is associated with reduced regional MDRO prevalence, incident clinical cultures, infection-related hospitalisations, costs, and deaths. 15 What factors in the workplace enable success in antimicrobial stewardship in paediatric intensive care? Efforts to mitigate AMR prioritise antimicrobial stewardship (AMS) interventions. These interventions typically focus on deficiencies in practice and providing negative or normative feedback. This approach may miss opportunities to learn from success. In this study, the authors aimed to identify factors that enable success in AMS practices in the paediatric intensive care unit (PICU) by analysing the data obtained from interviews with staff members who had achieved success in AMS. 16 WHO: The case for investment and action in infection prevention and control Infections acquired in health care settings, including those antimicrobial resistant, cause tremendous suffering to patients, families and health workers and pose a high burden on health systems. Most of these infections are preventable with appropriate infection prevention and control (IPC) programmes and practices and basic water, sanitation and hygiene (WASH) services. This WHO document provides the evidence on the expected return in investment in and guidance for implementing and monitoring the WHO global action plan on IPC at the country level. 17 NHS England: Digital vision for antimicrobial stewardship in England Effectively tackling the challenge of AMR requires a co-ordinated and strategic approach across healthcare settings. Antimicrobial stewardship is an important element of this work. This publication outlines the functionalities that clinical digital systems need to support optimal antimicrobial stewardship in primary and secondary care. 18 Putting patients at the centre of antimicrobial stewardship in Uganda: Why meaningful patient engagement is essential to beating antimicrobial resistance Although antimicrobial stewardship (AMS) has traditionally focused on prescribers, laboratories and health facilities, evidence from Uganda demonstrates a critical reality: a large proportion of antibiotic use occurs at community and household level. Without engaging patients and communities as partners, stewardship efforts remain incomplete and unsustainable. Annet Naguudi, Regina Kamoga and Joshua Wamboga from the Uganda Alliance of Patients’ Organizations (UAPO) argue that strengthening AMS in Uganda requires placing patients at the centre of the response and highlights the strategic positioning of the UAPO to lead this shift in line with national and global priorities. #Share4safety Are you a healthcare professional looking to share your frontline insights to help improve patient safety? Have you developed a resource or tool locally that others could benefit from? Or perhaps you have an experience to share around antimicrobial resistance? Get in touch with us by emailing [email protected] Join our global patient safety community the hub is an award winning platform, bringing together people from around the world who are passionate about patient safety and reducing unsafe care. It's free and easy to join so why not sign up today and join a growing community helping to drive safer care. -
Content ArticleStandardised nomenclature for combination formulations could “minimise confusion and prevent medication errors”, suggests the authors of this study. The authors identified 26 combination formulations with ‘co-drug’ names in the UK. Eleven were prescribed more than 2,000 times during 2023, including paracetamol + codeine (co-codamol), which saw an average of 1.26 million items dispensed each month; carbidopa + levodopa (co-careldopa – 114,656 items a month); dihydrocodeine + paracetamol (co-dydramol – 110,506 average monthly items; and amoxicillin + clavulanic acid (co-amoxiclav), with an average of 106,504 items a month. A literature review found examples of errors involving, with decreasing frequency, co-amoxiclav, co-amilofruse, co-beneldopa, co-careldopa, co-codamol, co-dydramol and co-trimoxazole. The authors noted that packaging of co-drugs can also be inconsistent. For example, some co-codamol products do not prominently display the individual active ingredients, while the strength is unclear on others. To reduce the risk of errors, the authors advocate a standardised nomenclature on the box and in prescribing resources so that the international non-proprietary name (INN) of each component is followed by the strengths in the x + y format.
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Content ArticleThe Royal College of Physicians (RCP) has published new interim guidance on the scope, supervision and employment of physician associates (PAs) working in the medical specialties (also known as the physician specialties). The interim guidance covers scope of practice for general internal medicine, supervision and employment of PAs, and how PAs should describe their role to patients, employers, other healthcare professionals and the public. It will be reviewed in collaboration with stakeholders, including RCP fellows and members, following the publication of the report of the Leng review. In the guidance, the RCP is clear that: PAs must support – not replace – doctors, have a nationally defined ceiling of practice, and have a clearly defined role in the multidisciplinary team (MDT). PAs must never function as a senior decision maker, nor should they decide whether a patient is admitted or discharged from hospital. Resident doctors are not, and must not be expected or asked to be, responsible for the clinical supervision of PAs. PAs should only be supervised by consultants, specialist or associate specialist doctors. PAs cannot prescribe medications regardless of any prior healthcare background while working as a PA. PAs must clearly explain their role to patients, their families and carers, as well as colleagues and supervisors, and provide details of their educational and clinical supervision when required.
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News Article
Prescription charges frozen in England
Patient Safety Learning posted a news article in News
Prescription charges in England will be frozen this year – for the first time since 2022. The charge for a single item will remain at £9.90 in 2025-26, the government has announced. Three-month and annual prescriptions prepayment certificates will also be frozen and existing exemptions will continue. Charges only apply in England as prescriptions are free in the rest of the UK. Nearly nine in 10 prescriptions in England are already dispensed free of charge, with children, over 60s, pregnant women, people with certain medical conditions and those on lower incomes exempt from paying. Rachel Power, chief executive of Patients Association which campaigns for improvements in health and social care, said freezing the charges was a "positive step". But she warned that it did little to tackle the "deep inequalities" in what she described as an outdated system. She said the medical exemption criteria had remained virtually unchanged since the late 1960s, with nearly three million people in England living with long-term conditions not eligible for an exemption because they were not recognised 60 years ago or people rarely survived into adulthood. Conditions which are not currently on the medical exemption list include Parkinson's disease, cystic fibrosis and motor neurone disease. "We urge the government to go further - to commit to a full review of the medical exemption list and prescription charges," Ms Power added. Read full story Source: BBC News, 28 April 2025 -
News Article
UK pharmacies could cut hours unless NHS provides ‘new and sufficient’ funding
Patient Safety Learning posted a news article in News
Independent pharmacies in England have been advised to slash their opening hours in a row over funding. The National Pharmacy Association (NPA) said it had “been left with little choice” but to recommend its 6,000 members take collective action for the first time in its history, unless the government provides “new and sufficient” funding to cover significant new costs. About 90% of an average pharmacy’s work is funded via the NHS, including dispensing medication and vaccinations. But the NPA, which represents community pharmacies, says members have yet to receive any confirmation of funding for the 2024-25 or the 2025-26 financial years. Increases in employers’ national insurance rates, the national living wage and business rates from April, on top of these unresolved funding issues could “jeopardise patient safety”, it says. Significant numbers of pharmacies have already ceased trading, with 1,300 pharmacies shutting since 2017. Nick Kaye, chair of the NPA, said the move was necessary “to safeguard patient services for the long term”, adding: “It is better that we temporarily reduce access in the short term than let pharmacies collapse." Read full story Source: The Guardian, 18 March 2025 -
News Article
Drug shortages putting patients at risk, pharmacists warn
Patient Safety Learning posted a news article in News
Patients are being put at risk of serious illness as pharmacists are unable to dispense vital medications due to drug shortages, industry leaders have warned. At least once a day drug supply problems mean pharmacies are unable to dispense a prescription, according to a survey of 500 pharmacies by the National Pharmacy Association (NPA). Currently if a prescription is out of stock, patients need to go back to their GP to get an alternative medication. But this can delay care and increase the risk of serious illness. That’s because the pharmacist is not permitted to make a substitution even if they have a safe alternative in stock, this is except in very limited circumstances where a Serious Shortage Protocol has been issued by the NHS. The NPA, which represents 6,000 independent community pharmacies, is calling on the government to grant greater flexibility for pharmacists to substitute medication or strength of a drug when it is safe to do so. The NPA says it is “madness” to send someone back to the GP and warned the current situation poses a risk to patient safety. It said it could lead to patients potentially going without vital medication, such as some types of antibiotics, presenting a serious risk to their health. Read full story Source: The Independent, 10 March 2025 Related reading on the hub: Medicines shortages: minimising the impact on patients Medication supply issues: A pharmacist’s perspective Medication supply issues: Mast cell activation syndrome (MCAS) -
News ArticleAn NHS chief is calling for a crackdown on the online sale and prescription of popular weight-loss jabs like Ozempic and Mounjaro following warnings from charities about an increase in people with eating disorders accessing the drugs. One clinician even warned that patients with low body mass index (BMI) or a history of anorexia are able to get an online prescription for the injections by filling out a simple patient questionnaire and lying about their body weight. “I am seeing patients who have pushed themselves to rapid weight loss on these jabs, fasting and strenuous exercising,” said Dr Adarsh Dharendra, a consultant psychiatrist specialising in eating disorders at Priory Life Works in Surrey. “Yet patients can still access so many rogue pharmacy websites on mainstream as well as the dark web.” NHS national medical director Professor Sir Stephen Powis urged online pharmacies and private providers to “act responsibly” and ensure that the drugs are only prescribed to people with a medical need for them, such as those with diabetes. Last month, the pharmacy regulator tightened prescription rules to prevent weight-loss medications from being supplied “inappropriately”, after groups including the National Pharmacy Association warned some online suppliers were wrongly prescribing the drugs to people who had previously had eating disorders. Read full story Source: The Independent, 4 March 2025
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News Article
USA: Trump casts psychiatric and weight-loss drugs as threats to children
Patient Safety Learning posted a news article in News
President Donald Trump has instructed his administration to scrutinize the “threat” to children posed by antidepressants, stimulants and other common psychiatric drugs, targeting medication taken by millions in his latest challenge to long-standing medical practices. The directive came in an executive order Thursday that established a “Make America Healthy Again” commission led by Health and Human Services Secretary Robert F. Kennedy Jr., who has criticized the use of those drugs and issued false claims about them. The order said the commission should prepare a “Make Our Children Healthy Again” assessment within 100 days that examines “the prevalence of and threat posed by the prescription of selective serotonin reuptake inhibitors, antipsychotics, mood stabilizers, stimulants, and weight-loss drugs.” The directive comes as children and teens endure a mental health crisis exacerbated by the covid pandemic. The medication review joins a slew of Trump administration policies upending the government’s approach to health, many of which are embroiled in legal challenges. They include attempts to remove vaccine information from health agency websites, to ban gender transition care for children and to cut billions in biomedical research funding. Kush Desai, a White House spokesman, said the order follows concerns about doctors overprescribing the drugs and harming Americans of all ages. The president called for a review of prescription practices and use of the drugs to determine whether the government should offer new guidance on the medication. Read full story (paywalled) Source: The Washington Post, 18 February 2025 -
News Article
Advertising regulator launches nine investigations into weight loss jab ads
Patient Safety Learning posted a news article in News
Nine investigations into weight loss jab adverts have been launched by the UK advertising regulator, which has raised concerns about the sheer volume of law-breaking involved in targeting the public with the drugs. The Advertising Standards Authority (ASA) told The Independent it now has nine high-priority investigations underway into whether ads in various online media are promoting prescription-only medicines (POMs) in breach of its rules and the law. Issues being probed include the use of unbranded injection or pen images, as well as claims such as “weight loss injections” and “Obesity Treatment Jab". The ASA described the number of investigations running in parallel on the same topic as “significant” and said that tackling the issue is a “priority”. Health secretary Wes Streeting has warned that the drugs “should not be taken to help get a body beautiful picture for Instagram” and must be treated as “serious medicines”. Drugs for weight management “should only be used by those tackling obesity,” he added. The pharmacy regulator has now tightened prescription rules to prevent weight-loss medicines from being supplied “inappropriately”, with people now no longer able to get the drugs after completing a simple online questionnaire. Groups including the National Pharmacy Association (NPA) had been calling for tougher rules after they learnt of people being wrongly prescribed the drugs without thorough checks, including some who already had a low body weight or who previously had eating disorders. Read full story Source: The Independent, 12 February 2025 -
News Article
Thomas Kingston's family calls for antidepressant prescription change
Patient Safety Learning posted a news article in News
The parents of Thomas Kingston have warned about the side effects of antidepressants after he took his own life. Mr Kingston died from a head injury in February last year at his parents' home in the Cotswolds. A gun was found near his body. The 45-year-old had stopped taking his medication, which had been prescribed by a GP at the Royal Mews Surgery in the days leading up to his death. His parents, Martin and Jill Kingston, are now calling for a change in how patients are prescribed selective serotonin reuptake inhibitors (SSRI) - a widely used type of antidepressant. Martin Kingston told BBC Radio 4's Today programme he believes both the patient and the people close to them should be told more explicitly about the potential side effects of the medication, including what can happen if they stop taking it. The couple want patients to sign a document confirming they've been told about the difficulties of going on and coming off the medication. This could include the patient being told that "it's an extreme case, but it could lead to suicide", Mrs Kingston says. "We'd really like to see that a person, a spouse, a partner, a parent, a close friend, somebody, was going to walk with them through it. Maybe they should be at that signing time." Recording a narrative conclusion at an inquest into his death in December, Katy Skerrett, senior coroner for Gloucestershire, said Thomas Kingston had taken his own life. "The evidence of his wife, family and business partner all supports his lack of suicidal intent," she said at the inquest. "He was suffering adverse effects of medication he had recently been prescribed." In a prevention of future deaths report, made in January, Ms Skerrett said action must be taken over the risk to patients prescribed SSRIs. She questioned whether there was adequate communication of the risks associated with such medication. Read full story Source: BBC News, 4 January 2025 Related reading on the hub: The question that will save lives: Interview with Katinka Blackford Newman, founder of Antidepressant Risks Long-lasting sexual dysfunction after taking antidepressants: Lack of recognition harmful to patients Post-SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect? -
EventuntilMedication errors are a leading cause of injury and avoidable harm in healthcare, with an estimated 1.3 million people impacted in the U.S. each year. Preventable medication errors cost the nation more than $21 billion annually across all care settings, representing a serious public health concern, as well as an economic burden on our healthcare system. Join AHRQ’s expert panel of speakers to hear how quality improvement approaches and digital healthcare interventions such as clinical decision support tools are reducing medication errors, improving provider effectiveness, and enhancing patient safety in a variety of clinical care settings. At the conclusion of this Webinar, participants should be able to: Discuss how an e-prescribing tool can reduce medication discrepancies and improve patient safety by enhancing communication between pharmacists and providers. Identify how clinical decision support systems can significantly reduce the prescribing of potentially inappropriate medications to older patients at the time of discharge from the emergency department setting. Explain how outcome measures, such as the Wrong-Patient Retract-and-Reorder measure, can be developed and used to detect medication errors in electronic orders. Register
