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Content Article
Francine Gilmore, a patient with vestibular migraine, has written a report in a personal capacity* examining a patient safety gap where migraine prescribing overlaps with mental health risk. Drawing on Freedom of Information responses from 26 organisations and related evidence, the report identifies fragmented safeguards, unclear ownership and potential barriers to suitable treatment for clinically complex patients. In this blog, Francine shares her experience, the findings from her report and the actions she would like to see taken. The findings point to a clear need for change: migraine pathways must make mental health risk visible, owned in governance, recorded in clinical systems and reviewed for patient-safety learning. *The full report can be downloaded from the attachment at the end of the page. My (wobbly) journey I did not set out to write a patient safety report. I was trying to understand why so many medicines with potential contraindications had been offered to me. Quite literally a year to the date, since returning from the USA after my 30th birthday, I have been living with ongoing symptoms of what is now known to be vestibular migraine. The dizziness is relentless. When the dizziness starts, I am a safety risk. The headache pain can make life unbearable. So can photophobia, when ordinary light becomes too much to tolerate. Sunglasses are my new best friend. Somewhere along the way, I entered a state of medical hypervigilance. I was angry, frightened and exhausted. It felt as though, in trying to repair my physical health, I was once again being asked to risk my mental health. Every treatment decision felt like a game of medical Whac-a-Mole: solve the migraine problem, worry about mental health issues popping up later. Returning to full-time work has been a huge achievement. But doing so while still managing pain, dizziness and photophobia has also shown me how much invisible effort this condition demands. Yet migraine is only part of my picture. I also live with bipolar disorder and have a history of suspected serotonin syndrome (a serious condition caused by medications that build up high levels of serotonin in the body requiring hospitalisation). That means migraine treatment is not simply about whether a drug might help. It is also about whether it could destabilise my mental health, interact with other risks or cause another kind of harm. There. I have disclosed it publicly, likely where my professional networks will see it. But I am saying it because it matters and I know the risks. Managed mental illness should not be a nice to have consideration; it should make joined-up prescribing decisions more important. Before appointments, I print reports listing the medicines I am concerned about. I sit there trying to explain what I can and cannot take, aware that I may sound difficult, but also aware that I am the person who will live with the consequences if those risks are missed. I could probably deliver a TED Talk entitled 10 Things I Hate About Migraine Prophylaxis Options. The trouble is that there are considerably more than ten. The evidence The report is based on Freedom of Information responses and related information routes. The project file covers 26 organisations or evidence routes and more than 30 documents, so 1000+ pages of evidence. I used AI as a research and drafting tool, but every substantive finding was checked against the underlying evidence. Given the volume of material and the impact of disabling migraine, this was an accessibility tool as much as a drafting tool. The Migraine Trust states that migraine affects around one in seven people. My report also cites systematic review evidence showing increased odds of depression in people with migraine, increased odds of anxiety, and estimated bipolar disorder prevalence among people with migraine of 5.9% in population studies and 9% in clinic-based studies. The relationship is clinically relevant because migraine, mood disorders and some preventive medicines can overlap through neurological, psychiatric and medication-safety pathways. For patients already managing mental health medication, migraine prescribing is rarely a cleanly separate issue. There is also crossover in the medicines themselves. Amitriptyline, venlafaxine and nortriptyline are antidepressants and migraine preventives, while topiramate and valproate raise neuropsychiatric or psychiatric safety considerations. Greater occipital nerve blocks may also involve steroid exposure. Only last week I was offered lamotrigine and had to point out that this is also a centrally acting medicine with psychiatric relevance, particularly for someone with bipolar disorder. What I found in my research was a system that could point to safeguards in theory, but not clearly show who owned the risk in practice. NICE guidance, the British National Formulary, product warnings, local formularies, prescribing systems, referral routes and clinical judgement all matter. For patients like me, that gap affects which medicines feel safe to try, how much responsibility we are forced to carry and whether the whole picture is visible to the people making decisions. It also affects access. Some patients cannot safely use standard migraine preventives because of psychiatric history, psychotropic medication, previous adverse reactions or physical contraindications. If access to some specialist treatments depends on trying previous prophylaxis options, pathways need to show how contraindication, intolerance or clinical unsuitability are recorded and counted. Otherwise, patients can fall into a cruel gap: too complex for the standard route but not clearly signposted towards safer alternatives The report makes practical recommendations: clearer flagging of mental health and medication-safety risks defined ownership of the prescribing interface triggers for psychiatry or specialist pharmacy input better documentation and escalation processes recognition of contraindication, intolerance and clinical unsuitability when assessing access to specialist migraine treatments. Parliamentary questions asked On the eve of Patient Safety Learning publishing my report and blog, something unexpected happened. A number of parliamentary questions had already been tabled in the House of Commons about the issues the report raises. To me, the early answers seemed to confirm the gap the report had identified. On 15 June 2026, the Department of Health and Social Care (DHSC) said it had made no specific assessment of national arrangements for identifying, recording and acting on psychiatric history, psychotropic medication or previous psychiatric adverse drug reactions before someone starts a preventive migraine treatment. A second answer pointed to the Getting It Right First Time (GIRFT) programme as a way of reducing variation in migraine access. That sounded promising, until two follow up answers narrowed the position again. The DHSC then confirmed it had no plans to look any further than its 15 June position. Asked whether GIRFT covers governance for this prescribing interface, it confirmed on 1 July that it does not. GIRFT sets no formal governance requirements here. Those decisions are left to local providers and commissioners. Then came the House of Lords answer. On 6 July, the Government confirmed that the Medicines and Healthcare products Regulatory Agency (MHRA) now plans to review the evidence on mental health and related risks for licensed migraine prophylaxis medicines after receiving a report from a patient. It will consider whether product warnings need updating, and will look at suspected adverse drug reactions reported in the psychiatric disorders category. The answer records that this followed a report made to the MHRA. So the question is no longer just whether the risks are recognised. It is this: if the MHRA moves, how quickly will the rest of the system move with it? -
News Article
Daily weight loss pill available in UK pharmacies from today
Patient Safety Learning posted a news article in News
Pharmacies are “bracing themselves” for an influx of patients seeking weight loss drugs as the Wegovy pill becomes available. The Wegovy tablet, manufactured by Novo Nordisk, became the first GLP-1 pill for weight loss to be approved by the UK’s medicines regulator last month. The starting dose is 1.5mg, gradually increasing to 4mg, 9mg and 25mg, with patients required to remain on each dose level for at least a month before progressing. From Monday, the initial 1.5mg and 4mg doses will be accessible to eligible patients through weight management programmes in select pharmacies. A recent survey conducted by the National Pharmacy Association (NPA) among 310 pharmacies revealed that 76 per cent expect to start a significant number of new eligible patients on the pill in the coming months. Olivier Picard, chairman of the NPA, said: “This is a significant day and pharmacies are bracing themselves for a surge in demand for this new form of weight loss treatment. This is particularly significant for patients who cannot or do not want to take an injectable medicine. “The NHS rollout remains extremely slow and community pharmacy is ready to support a wider rollout, which will help eligible patients access treatment safely and help mitigate the impact of obesity on the NHS.” Read full story Source: The Independent, 6 July 2026 -
Content ArticleDon't risk your health: always check an online pharmacy is on our register before you use it All legitimate pharmacies operating in Great Britain have to be on the General Pharmaceutical Council’s register. Fake online pharmacies are operating illegally, and sell medicines that are unsafe and could cause you serious harm. Check the pharmacy register now.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency (MHRA) regulates medicines, medical devices and blood components for transfusion in the UK. This roundup provides a summary of their latest safety advice for medicines and medical device users. It includes details of medicine recalls, medical device field safety notices and details of how to report drug reactions and device incidents. This month's Safety Roundup includes: Drug Safety Update on ACE-inhibitors: Be aware of the distinction between bradykinin- and histamine-mediated angioedema, as treatment strategies differ significantly. Letters, medicines recalls and device notifications sent to healthcare professionals in June 2026 . News and guidance on: MHRA launches AI sandbox to accelerate medicines development and improve safety.
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Content ArticleIndependent online prescribing has expanded rapidly in recent years, driven by increased patient demand for convenience, long NHS waiting times for some services, and a broader shift toward digitally enabled models of care. This Health Services Safety Investigations Body (HSSIB) investigation focuses on challenges for independent prescribing organisations in accessing clinical information held by the NHS to inform safe prescribing decisions for the patients who use their services. It also explores how gaps in NHS patient information about medication prescribed by independent prescribing organisations creates risks for the delivery of safe care. For both NHS and independent prescribing organisations, having limited information about a patient’s medical history and the medications they are being prescribed creates a challenge to making safe decisions about ongoing care and treatment. The investigation also explores the complex regulatory landscape within which independent prescribing organisations sit. In this regulatory framework, regulators may have jurisdiction over different aspects of a single independent prescribing organisations. The investigation explored the challenges this posed and the impact it had on these organisations’ ability to provide safe care. The findings of this investigation are offered to support the safe delivery of care for patients who use independent prescribing organisations and NHS services. Findings Independent prescribing organisations without an NHS contract do not typically have access to a patient’s NHS medical records. This can affect their ability to verify patient information. Some independent prescribing organisations use photos or videos of a patient’s NHS App to verify information about the patient’s medical history. This is beyond the purpose of the NHS App and creates patient safety risks as the app is not designed to hold a verified complete picture. Independent prescribing organisations have systems to identify multiple requests for medication from the same patient, address or payment method, but this information is not currently shared outside of their organisation. No independent prescribing organisations currently have ‘write access’ to patients’ NHS medical records – that is, the ability to enter information directly into a record. This creates the potential for gaps in medical records which can impact on the identification of potential contraindications (factors in an individual's condition or medical history that make it unwise to pursue a particular line of treatment) and complications. NHS GPs are being relied upon to provide clinical information to independent prescribing organisations but have limited capacity to provide this. The different approaches to such information requests also create uncertainty among GPs around whether the requests are legitimate and whether they should respond. Lack of access to patients’ NHS medical records is a barrier to independent prescribing organisations providing safe care in line with standards, regulations, and best practice. A large amount of data is gathered by independent prescribing organisations which could inform patient care, but there is no way to feed this back into the NHS. This data often relates to medications more commonly prescribed by independent prescribing organisations, such as those for weight loss, and has implications for understanding the safety of these medications. The Care Quality Commission and General Pharmaceutical Council have arrangements to work together in relation to organisations registered with both regulators, but these arrangements could be made clearer to providers. HSSIB makes the following safety recommendations HSSIB recommends that the Department of Health and Social Care develops a policy and implements a mechanism to enable appropriate NHS patient information to be shared with independent prescribing organisations. This is to ensure independent prescribing organisations can access verified patient information, with patients’ consent, to inform prescribing decisions. HSSIB recommends that the Department of Health and Social Care undertakes a review to explore the options and determine an appropriate mechanism for write access to health records for independent prescribing organisations. This would inform future developments such as the Single Patient Record, improve the currency of patient information held digitally by NHS organisations, and may remove some burden from general practices. HSSIB recommends that the Department of Health and Social Care works with relevant organisations, including Digital Clinical Excellence and the Coalition for Responsible Digital Health, to develop a framework to enable the sharing of safety critical information relating to patients known to multiple independent prescribing organisations. This would create a cross-organisational safeguard for patients who may be at risk of harm, and supporting safe prescribing. HSSIB makes the following safety observations Independent prescribing organisations can improve patient safety by ensuring that patient information contained in the NHS App is not used as a sole source of verification when making clinical decisions, as this is outside the purpose of the App and can result in patient safety risks. National healthcare organisations and independent prescribing organisations can improve patient safety by working together to design mechanisms for receiving information held by independent prescribing organisations. Such data may help to inform NHS care and provide insights into the safety profile of medications predominantly prescribed in the private sector.
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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 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
