BMJ Qual Saf 20:360-365 doi:10.1136/bmjqs.2010.040287
  • Error management

An assessment of the quality and impact of NPSA medication safety outputs issued to the NHS in England and Wales

  1. Saul N Weingart3
  1. 1Cardiff School of Nursing and Midwifery Studies, Eastgate House, City Road, Cardiff, UK
  2. 2York Health Economics Consortium, Market Square, University of York, UK
  3. 3Harvard Medical School and Dana-Farber Cancer Institute, Boston, USA
  1. Correspondence to Dr Annette Lankshear, Reader in Health Policy, Cardiff School of Nursing and Midwifery Studies, Cardiff University, Eastgate House, City Road, Cardiff CF24 0AB, UK; lankshearaj{at}
  1. Contributors KVL was project director and set up and analysed survey material. AJL ran focus groups, conducted interviews and carried out all qualitative analysis. SNW compared NPSA outputs with those from other international bodies, conducted key high level interviews and provided external advice and support to the team.

  • Accepted 20 August 2010
  • Published Online First 8 February 2011


Objectives To assess the quality and impact of medication safety outputs issued by the National Patient Safety Agency (NPSA) to the NHS in England and Wales.

Methods A multi-method study comprising (1) focus groups and interviews with NHS Chief Pharmacists and (2) an electronic survey of medical, nursing and clinical governance directors.

Results Acute sector respondents agreed that the medication outputs had a major impact on patient safety. Pharmacists welcomed national support for medication safety improvement, despite the resulting workload. Medical Directors were much less likely to be aware of alerts and Rapid Response Reports (RRRs) than their nursing and clinical governance colleagues. One key finding was the inability of around half of NHS trusts to communicate effectively and reliably with their junior doctors.

Conclusion Medication alerts issued by the NPSA have stimulated significant work to improve medication safety and are believed to have had an important impact on patient safety.


  • Funding National Patient Safety Agency, 4-8 Maple Street, London W1T 5HD, UK. Other Funders: National Patient Safety Agency.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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