It has been estimated that 67% of patients’ prescription medication histories have one or more errors and up to 46% of medication errors occur when new orders are written at patient admission or discharge. (Joint Commission International Center for Patient Safety).

Service Description

The programme aims to bring together current improvement activity related to medicines from across the SPSP Acute Adult, Primary Care, MCQIC and Mental Health programmes. The Medicines programme was launched in early 2015 and the first phase of our work focuses on medication reconciliation across different healthcare settings and high risk medicines. Building on existing improvement activity within SPSP, we are supporting healthcare staff to take a ‘whole system approach’ to medicines, considering the patient as they move between care settings and home. Working with patients and all members of the multidisciplinary team is essential.


The programme is open to all NHS boards and Health and Social Care Partnerships and has a focus on high risk medicines and medication reconciliation across different healthcare and community settings.


NHS boards

Benefits of programme

Medication reconciliation has been shown to reduce errors at the point of transition. A study in Scotland demonstrated a reduction in the prescribing error rate from 3.3 errors to 0.04 errors per patient when medication reconciliation was performed on admission to hospital (Mills et al, Emerg Med J 2010;27:911e915). Evidence of the impact of medication reconciliation in primary care is limited; however, one study demonstrated a 50% reduction in the average number of discrepancies per patient regarding their medicine after medication reconciliation in the primary care setting was completed (Vakey et al, Jt Comm J Qual Patient Saf 2007;33:286-92). SPSP Medicines is supporting existing improvement activity targeting medication reconciliation on admission to and discharge from hospital, for acute care, mental health and womens and childrens service. Links are also being made with existing work within primary care (general practice and community pharmacy).

High risk medicines have been described as medicine with a low therapeutic index; medicines that present a high risk when administered by the wrong route or when other system errors occur; and medicines that requires dose / frequency modification according to specific parameters. Evidence regarding improvements in the context of high risk medicines is being developed and the proposal is to do initial testing work to assess the opportunities for/ impact of improvement.


David Maxwell