We can all help to make medicines safe

It is also well recognised by all those who prescribe that errors made in the prescribing, dispensing and administering can have consequences and that these not only can cause harm but can also lead to mistrust and non-compliance of patients resulting in failures in treatment or prevention of deterioration. 

Through the years, a number of tools have been developed and are used to ensure medication is not only prescribed but given safely. The introduction of electronic prescribing has led to a substantial decrease in medication errors but as with any system there are flaws. The automated triggers developed within the electronic prescribing systems enables the identification of drug allergies and interactions. It also enables settings to be introduced such as a request for body weight when someone is starting on paracetamol so that an appropriate dose reduction is available for those weighing below 45kg. Not all inpatient prescribing is electronic and we still see in our hospitals the use of paper charts/pathways for the management of diabetic emergencies such as diabetic ketoacidosis and in other parts of the world where they do not have the luxury of electronic prescribing there remains a burden on the prescriber to remember important fact such as the risks associated with co-prescription of methotrexate and trimethoprim.

It is recognised that one of the benefits of electronic prescribing are errors due to the illegibility of handwriting or the inappropriate dosage of medication and these have reduced since electronic prescribing systems have been introduced. The ability for doses to be recorded clearly not only numerically have prevented the administration of incorrect doses for example the administration of 25mg of morphine instead of 2.5mg. Similarly, the improved prescribing seen by the advocation that insulin be prescribed as units with units written out in full instead and even more so when electronic systems have taken over that function so that the U often recorded in handwritten prescriptions is not misinterpreted as a 0 leading to overdoses of insulin. Electronic systems as we move from analogue to digital enable the streamlining of prescribing to make it more efficient and therefore safe, for example by introducing / reminding prescribers about the protocols in a given organisation such as antimicrobial guidance. The systems can also be configured so it is clear which medication is on the formulary, alternatives for those unavailable or prompt staff to ask patients and relatives to medication so important drug treatments such as chemotherapy are not missed.

National systems are also in place to improve prescribing and highlight areas of concern from those issued by the National Patient Safety Alert system, such as the incorrect documentation of penicillin rather than penicillinamine allergy or indeed the use of steroid cards to ensure those on steroid cards are highlighted to medical/ nursing professionals looking after them. We as physicians, also alongside other prescribing professionals and patients themselves have the ability to report drug side affects to the Medicine and Healthcare products Regulation Agency (MHRA). Indeed, in 2024-2025 the MHRA assessed over 100,000 adverse drug reports and blocked over 1.5 million unregulated online listings of medicines. They also approved more than 2,000 licences for medication including 54 new treatments, such as treatment for Alzheimer’s, rare conditions and cancer.

However, medication related harm and indeed death still occurs. With this in mind, the Joint Working Safety Group of the Royal Pharmaceutical Society and the Royal College of Physicians reviewed all the deaths where HM Coroner from the 1 January and 30 August 2025 had released a Prevention of Future Death which were defined as alcohol, drug and medication related. A total of 69 deaths in total. The majority of these were due to overdose of either an illicit medication or a prescribed substances available to the person that died and not reviewed as part of this review. 18 of the 69 deaths were related to prescribed medications and covered the following themes (some were related to more than one theme):

a) Lack of adequate monitoring of medication/ advice re side effects with recognised life-threatening side effects

b) Opioid toxicity in a patient with chronic kidney disease also associated with poor education in management of opioid toxicity

c) Delay in obtaining medication:

a. Prescribing restrictions in children’s prescriptions

b. Unavailability at local pharmacy

c. Inpatient hospital ordering delays

d. Insufficient supply given (28 days medication being seen as a month’s worth when a month can vary from 28-31 days)

d) Failure to diagnosis acute illness resulting in delay in delivery of time critical medication

e) Insufficient knowledge about risks of drug use (1 was an illicit substance)

f) Failure to consider alternative route administration for a medication

g) Failure to safely prescribe:

a. In a patient with known drug allergy

b. Patient of low body weight

h) Delays in Specialist-GP communication – leading to over prescription of medication