Improving Prescribing Safety and Reducing Patient Risk

Healthcare problem

Medication errors are common in primary care and cause significant patient harm, with over a billion prescriptions issued annually in England and errors contributing to more than seven times more avoidable deaths than in secondary care. Around 5% of UK general practice patients are exposed to potentially hazardous prescribing and about 12% lack appropriate monitoring, underscoring the need for continuous systems to identify and prevent medication safety risks.

Innovation

In partnership with Graphnet Health, a UK‑based supplier of shared care record software, population health tools, and clinical solutions for the NHS, we developed the Safety Medication dASHboard (SMASH) — a digital tool that helps pharmacists and GPs reduce hazardous prescribing by flagging patients who may be at risk from the medicines they are prescribed in general practice.

The groups of patients identified by the application are based on a set of evidence‑based prescribing safety indicators, agreed by experts, which describe potentially hazardous prescribing situations.

Once identified, the healthcare professional can open the patient’s medical record in their own system to determine how best to address and correct the issue.

Outcomes

SMASH was evaluated in 43 general practices covering a population of 235,595 people in Salford.

It has now been rolled out regionally via the Greater Manchester Care Record (GMCR), covering 3 million people.

Support and funding

This project was a collaboration between the NHS (Greater Manchester Integrated Care Partnership), academia (The University of Manchester), and industry (Graphnet).

Support and funding from the National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Research Collaboration (GM PSRC) were crucial to its success.

The NIHR GM PSRC contributed essential research capacity and expertise, led by their Improving Medication Safety research theme.

Relevant publications

• Evaluation of a pharmacist-led actionable audit and feedback intervention for improving medication safety in UK primary care: An interrupted time series analysis.
• Developing a learning health system: Insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care.
• Understanding the utilisation of a novel interactive electronic medication safety dashboard in general practice: a mixed methods study.

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