The Trust's Medication Safety Officer (MSO) is responsible for overseeing medicine safety issues and ensuring that any problems are highlighted and communicated within and externally to the Trust. This is facilitated by sending QPAs to key members of staff and managers, through huddles and safety panels, and through this webpage. Copies of QPAs sent are listed below.

MSO is Yasmin Issa

Email: MSO@merseycare.nhs.uk

Our Perfect Care Goals for 24/25 are: 

1) Zero moderate / severe harm incidents relating to medicines

2) Zero harm from prescribing, administration and management of controlled drugs

3) Zero harm from Valproate

4) Zero medication administration errors linked to patient misidentification

Community Care Division MISH Templates

MISH Chronology Template

Reflective Practice Template

Medicines shortages report Oct 2024

SPS Medicines Supply Tool

 

A National Patient Safety Alert sets out actions healthcare organisations must take to reduce the risk when a new or under recognised patient safety which requires national action is identified.

 

​Historically, a number of  systems have existed across the Pan Mersey area to collect and share interface problems related to medicines with a view to reducing common problems.

Incidents are fedback  to the individual organisation via the trust governance processes. 

 

What are interface issues?

An interface issue is any event that may cause a problem in the management of medicines between different organisations:

  • Prescribing not in line with Cheshire and Merseyside APG policies/ formulary
  • Inappropriate request for shared care
  • Request for an unlicensed medicine
  • Request for vaccine outside of guidance
  • Inaccurate medication record
  • Summary Care Record not up to date
  • Illegible or ambiguous information relating to prescribing
  • Lack of discharge or reconciliation information
  • Lack of referral to NHS Community Services for follow up or ongoing treatment
  • Incorrect medication
  • Inappropriate changes to medication
  • Medicines waste that could be avoided
  • Incomplete medication - items unknowingly omitted
  • Insufficient medication - items knowingly owed

 

The issue must first be highlighted with the relevant organisation and any appropriate action required to maintain safe ongoing patient treatment should be dealt with at the time. Any applicable internal incident policies should also be followed.

 

Interface incidents for St Helens CCG should be reported using the Interface incident form for St Helens CCG

The MSAT was developed to improve the management of medicines related risk to patients. It is intended to provide commissioners with a systematic way of identifying and analysing emerging medicines safety issues and engage with providers to reduce medicines related harm.

It includes useful advice for healthcare professionals on high risk medicines.

​​Reducing risks for transfusion-associated circulatory overload​ ​(NatPSA/2024/004/MHRA​) - April 2024

Valproate: organisations to prepare for new regulatory measures for oversight of prescribing to new patients and existing female patients (NatPSA/2023/013/MHRA) - November 2023

Potential risk of underdosing with calcium gluconate in severe hyperkalaemia (NatPSA/2023/007/MHRA) - June 2023

Recall of Emerade 500 micrograms and Emerade 300 micrograms auto-injectors, due
to the potential for device failure (NatPSA/2023/004/MHRA)- May 2023 

Prenoxad 1mg/ml Solution for Injection in a pre-filled syringe, Macarthys Laboratories,
(Aurum Pharmaceuticals Ltd), caution due to potential missing needles in sealed kits- National Patient Safety Alert November 2022

Class 4 Caution In Use Medicines Notification; Supplementary information:
Prenoxad 1mg/ml Solution for Injection in a pre-filled syringe (NatPSA/2022/009/MHRA)
Information for confirmed or potential holders of Prenoxad kits- Novemember 2022

Targocid 200mg powder for solution for injection/infusion or oral solution National Patient Safety Alert October 2022 

Potassium permanganate National Patient Safety Alert April 2022

Potassium permanganate (British Association of Dermatologists) Patient Information Leaflet

Potassium permanganate (British Association of Dermatologists) Guidance on minimising risk of harm from potassium permanganate soaks

QPA 2023-06 Inadvertent Oral Administration of Potassium Permanganate 17.1.23

This guidance is applicable to former Mid Mersey sites - this is yet to be aligned with similiar existing MCFT guidance.

RADAR Guidance / Reporting / Reflective Analysis

​The Medicines and Healthcare Products Regulatory Agency (MHRA) ensures the safety and efficacy of medicinal products and devices and communicates any issues.