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National Patient Safety Agency

Webinar: Safety in Doses

8 October 2009


The National Patient Safety Agency (NPSA) will hold a webinar on Wednesday 22 October from 12:30pm to 1.30pm to present the recently published 'Safety in Doses' report, to open up a forum for discussion and feedback to the NPSA. 

Safety in doses: Improving the use of medicine in the NHS is a detailed analysis of 72,482 medication incidents which occurred in 2007 and were reported to the NPSA's Reporting and Learning System. We have worked with NHS staff in several sectors to analyse these incidents.

Recommendations in the report include:


  1. NHS organisations should review the number and completeness of medication incident reports received locally to identify whether current arrangements are enabling local learning and action to minimise the risk of harm to patients.

    • Actions include:

      • comparing the organisation’s reporting performance in relation to similar organisations

      • gap analysis questioning ‘how are we doing?’

      • assessing the local reporting culture

      • identifying and managing local barriers to incident reporting.

  2. The information and incident examples in chapter 3 of the report relating to deaths and severe harm could be used to risk assess and, where necessary, improve the safety of local medication management systems.


NHS staff who are involved in improving the use of medicines or those who have a general interest in medication safety are invited to attend.


No special equipment is needed to participate – all you need is a web browser and a telephone connection.


Register for the webinar here
You will receive a confirmation email with instructions for joining the meeting. There are limited places available so please register as soon as you can.