The Trust Medication Safety Officer (MSO) is responsible for overseeing medicines safety issues and ensuring that any problems are highlighted and communicated in the Trust. This is facilitated by sending QPAs to key members of staff and managers, copies of QPAs sent are listed below.
The MSO is Yasmin Majeed Yasmin
- Rowlands Pharmacy Temporary Closure Hollins Park Pharmacy- 07.08.23
- QPA 2023-42 Prescribing on paper records for wards that have EPMA- 14.08.23
- QPA 2023- 40 Potent Synthetic Opioids Implicated in Heroin Overdoses and Deaths- 03.08.23
- Temperature Excursions Poster QPA 2023- 38a
- QPA 2023- 38 Dealing with Temperature Excursions- 28.07.23
- QPA 2023-36 Quetiapine Modified Release (MR)– Good practice prescribing- 27.07.23
- Medicine Related Policy Procedure Update- 07.07.23
- QPA 2023- 32 Aripiprazole and Impulsive Behaviours - 22.06.23
- QPA 2023-30 Melatonin Good Practice Prescribing Principles- 12.06.23
- QPA 2023-23- Amended Urgent Class 1 Recall of Emerade Auto-injector V2- 12.06.23
- QPA 2023- 31 GlucoRX HCT External Quality Assurance- 12.06.23
- QPA 2023- 27 Internal Transfer of Care; Inpatient Medication Records & Clinical Notes- 25.05.23
- QPA 2023- 24 Good Practice Prescribing of Antimicrobials- 15.05.23
- QPA 2023- 23 Urgent Class 1 Recall of Emerade Auto-injector- 11.05.23
- QPA 2023-22 Administration of antipsychotic depot injections in the acute hospital setting- 05.05.23
- QPA 2023-17 Raising awareness of sodium nitrite as a suicide agent - 05.04.23
- QPA 2023-16 Patient Identification- 13.03.23
- QPA 2023-15 Clonazepam added to restricted drug list - 08.03.23
- QPA 2023-13 Swich to a new formulation of paliperidone palmitate- 17.01.23
- QPA 2023-6 Inadvertent Oral Administration of Potassium Permanganate- 17.1.23
- QPA 2023- 1 Safe prescribing of medication, ensuring accuracy of medication records- 03.01.23
- QPA 2022- 82 Valproate prescribing for girls and women of childbearing potential-13.12.22
- QPA 2022-81 BNF access – a requirement for all staff working with medicines- 12.12.22
- QPA 2022-79 prescribing and administration of regular and when required medication- 18.11.22
- QPA 2022-77 Raising awareness of Neuroleptic Malignant Syndrome 003- 18.11.22
- QPA 2022-74 Recording Allergy Status on EPMA -16.11.22
- QPA 2022-73 Important update Rapid tranquilisation Policy and Procedures- 7.11.22
- QPA 2022-72 Sickle Cell Disease: Raising awareness of the disorder, key signs and symptoms and reccomended management of acute painful sickle cell crisis- 4.11.22
- QPA 2022-58 Watch Out for Look-alikes & Sound- alike Medicines- 10.08.22
- QPA 2022-55 Reminder of staff responsibilities when issuing medication against a Patient Group Direction (PGD) (2)- 04.08.22
- QPA 2022-56 Reminder of the increased risk of suicidal ideation- 03.08.22
- QPA 2022-52 Pregabalin (Lyrica) findings of safety study on risks during pregnancy v.2- 27.07.22
- QPA 2022-51 NovoRapid Insulin 100units in 1ml and Saxenda liraglutide 6mg in 1ml Pre-filled Pen- 22.07.22
- QPA 2022-49 Prescribing ‘Dummy Drugs’ on the Electronic Prescribing Medicines Administration System (EPMA)- 22.07.22
- QPA 2022-44 Reminder of staff responsibilities relating to Controlled Drug activities (002)- 05.07.22
- QPA 2022-39 Safe Temperature Storage Conditions for Medication and Dressings- 23.06.22
- QPA 2022-36 Safe Prescribing of Oral Paracetamol in Patients Aged 16 Years and Over- 30.05.22
- QPA 2022-34 Alcohol Detox POMH Audit Findings- 27.05.22
- QPA 2022-35 Clozapine toxicity associated with change in smoking status- 27.05.22
- QPA 2022-31 Reminder of Under-Recognised Risk of Severe Toxicity from Propranolol Overdose- 22.05.22
- QPA 2022-24 Standards. compliance scores. key points identified inMid Mersey POMH national audit_Clozapine- 27.04.22
- QPA 2022-15 New perinatal guidelines on physical health monitoring with psychotropic medication-18.03.22
- QPA 2022-14 Clozapine_ Reminder of potentially fatal risk of intestinal obstruction faecal impaction and paralytic ileus- 15.03.22
- QPA 2022-03 Use of combinations of depots or long-acting antipsychotics is not recommended v.2- 20.01.22
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.
Quarterly Medicine Alert reports can be found below:
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.
The Pan Mersey APC safety sub-group has created a single form and logging system for this purpose for use within the Pan Mersey area.
A Pan Mersey Interface Incident form should be completed for all interface incidents (using the link below).
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 Pan Mersey policies or 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 on-going treatment
- Incorrect medication
- Inappropriate changes to medication
- Medicines waste that could be avoided
- Incomplete medication - items unknowingly omitted
- Insufficient medication - items knowingly owed
Purpose of the Interface Log
The interface incident form is purely for logging an issue after the event. 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.
The information collected is used highlight medicines interface problems, collate common issues and support collaboration towards improvement. The interface log is not for dealing with unresolved individual problems.
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.
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
This guidance is applicable to former Mid Mersey sites - this is yet to be aligned with similiar existing MCFT guidance.
DATIX Guidance / Reporting / Reflective Analysis
- Reflective Tool
- Reflective Tool notes
- Guidance for Managers Reviewing Medication Incident DATIX Reports (IR2)
The Medicines and Healthcare Products Regulatory Agency (MHRA) ensures the safety and efficacy of medicinal products and devices and communicates any issues.