As the evidence suggests, the rate of prescribing errors in primary care is at least 11% and adverse drug reactions account for around 7% of hospital admissions . Effective communication between GPs, hospital staff and pharmacists in primary care is essential to reducing these numbers and achieving a whole-systems approach to patient safety.

Service Description

The pharmacy arm of the SPSP Primary Care programme is working to forge stronger links between GPs, hospital staff and pharmacy teams to drive improvement in the prescribing and dispensing of medication to patients after they’ve been in hospital. The focus is on the safe prescribing, monitoring and dispensing of high risk medicines using a care bundle. We are also seeking to improve the reliability of medicines reconciliation when patients are discharged from hospital and raise awareness of the factors that contribute to a safety culture. Four NHS boards are participating in this two-year collaborative:

  • NHS Fife
  • NHS Grampian
  • NHS Greater Glasgow and Clyde; and
  • NHS Highland

The learning from the two-year project will inform future pharmacy work within the Scottish Patient Safety Programme – Primary Care. The collaborative has been funded by the Health Foundation’s Closing the Gap in Patient Safety Programme.


Four NHS boards are participating in this 2-year collaborative which ends in September 2016: NHS Fife, NHS Grampian, NHS Greater Glasgow and Clyde, and NHS Highland. The learning from the 2-year project will inform the programme's future pharmacy work. Learning is shared within local and national learning events and accessible within the SPSP website and associated communities of practice websites.


Pharmacy teams and GPs working in primary care in NHS boards and community pharmacists

Benefits of programme

Reducing the risks associated with the use High Risk Medicines and specifically non-steroidal anti-inflammatory drugs (NSAIDs) was chosen as an area of focus because NSAIDs are more likely to be associated with emergency hospital admissions due to adverse drug reactions than any other drug class. NSAIDs are both dispensed and sold over the counter in pharmacies and are prescribed frequently. The bundle was developed specifically so it could be delivered for every patient, every time an NSAID was dispensed/sold at any pharmacy.

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). 


Jill Gillies


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