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Review of the outputs of the NPSA's Safer Medication Team

The review, undertaken by Annette Lankshear, Karin Lowson (York Health Economics Consortium) and Saul Weingart (Dana Farber Institute in Boston) sought to examine the selection of topics and the development, dissemination, implementation of guidance.  It also sought to the perceived impact of these work products on clinical care and outcomes. 

The study encompassed a total of 34 outputs including two patient safety observatory reports, ten safety alerts, ten rapid response reports, design advice and e-learning modules commissioned from BMJ e-learning.

We used a mixed method approach including inter-alia, interviews with a variety of stakeholders, focus groups and interviews with Chief Pharmacists and surveys of all Medical, Nursing and Clinical Governance Directors in acute and mental health trusts in England and Wales

We found general satisfaction with the rigorous, well-structured, and appropriate process for identifying topics for analysis and notification, whilst recognising the limitations of reliance on a reporting system to which primary care contributes little. Respondents reported that the large and complex alerts (such as those for anticoagulants and injectable medicines) have given rise to a significant (albeit necessary) workload in acute trusts.  A number of respondents expressed concern about the volume of prescribing errors being detected through pharmacy intervention systems.  Overall, only around one half of Medical Directors (but a significantly higher number of Nursing and Clinical Governance Directors) recall receiving medication outputs.  There is a view that relying on PCOs to disseminate guidance to GPs reduces the effectiveness of the message, and that direct dissemination to GPs from a respected source might encourage implementation.