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Patient Safety Observatory Report 4: Safety in doses

Safety in doses
Reference number
Issue date01 January 2007
TypeData report

This Patient Safety Observatory report analyses nearly 60,000 reported medication safety incidents reported by staff, as well as litigation and negligence data. It provides a detailed description of the learning from these reported incidents.


The incidents were reported to the National Reporting and Learning Service (NRLS) between January 2005 and June 2006. It brings together the key messages from reports to the NRLS and evidence from published research and data from other organisations, for example the NHS Litigation Authority.


The vast majority (over 80 per cent) of medication incidents reported to the RLS were from hospitals, even though most patient contact happens in the community.


The report recommends seven key actions for staff, NHS organisations and healthcare commissioners to improve medication safety: 


1. Increase reporting and learning from medication incidents.
2. Implement NPSA safer medication practice recommendations.
3. Improve staff skills and competences.
4. Minimise dosing errors.
5. Ensure medicines are not omitted.
6. Ensure the correct medicines are given to the.
7. Document patients’ medicine allergy status.


In addition, the report contains local practice examples showing the some of the actions that have been taken by individual trusts to reduce the risk of medication safety incidents.

Safety in doses - Patient Safety Observatory
Safety in doses - Patient Safety Observatory - 1.20 MB 0486 - Safety in doses - Patient Safety Observatory - 2007 - V1