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Building a safer NHS for patients: Improving Medication Safety

A report by the Chief Pharmaceutical Officer

  • Document type:
  • Author:
    Smith Jim
  • Published date:
    22 January 2004
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Errors occur in the prescribing, dispensing and administration of medicines. They can have serious consequences and they are invariably preventable. This report explores the causes and frequency of medication errors, highlights drugs and clinical settings that carry particular risks, and identifies models of good practice to reduce risk.

Copies are available from:
Chief Pharmaceutical Officer
Department of Health
Eileen House, 80-94 Newington Causeway
London SE1 6EF

Foreword by the Parliamentary Under Secretary of State for Health

The Chief Medical Officer's report to Ministers in 2000, An Organisation with a Memory, set out a challenging agenda for improving care by reporting and learning from adverse events. This innovative approach has attracted attention in health care systems throughout the world. We have moved swiftly to implement its key recommendations.

The National Patient Safety Agency, established in 2001, has the responsibility of improving the safety and quality of patient care through reporting, analysing, and disseminating the lessons of adverse events and 'near misses' involving NHS patients. It is the first truly national agency of its type anywhere in the world.

Our overriding aim is to embed a culture of safety in all NHS treatment, whether in hospitals or in primary care. Ensuring that drug treatment is safe is central to this strategy.

A prescribed medicine is the most frequent treatment provided for patients in the NHS. GPs in England issue more than 660 million prescriptions every year, and there are an estimated 200 million prescriptions in hospitals. Standards of prescribing in this country are high and the majority of drug treatment is provided safely.

However, mistakes do occur. They can arise in the prescribing, dispensing or administration of medicines. And the consequences can be serious for patients, their family and friends - and for the health professionals involved. We are therefore committed to making drug treatment as safe as possible. This report from the Chief Pharmaceutical Officer is a further step towards this aim. It provides guidance for health professionals and NHS organisations, drawing on experience and good practice within the NHS and worldwide.

With the developing work programme of the National Patient Safety Agency, and as part of our overall drive to improve quality and safety of care, these recommendations will help make drug treatment safer for NHS patients.

Lord Norman Warner

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