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Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes
National Institute for Health and Care Excellence
Systems for identifying, reporting and learning from medicines‑related patient safety incidents
Organisations should support a person‑centred, 'fair blame' culture that encourages reporting and learning from medicines‑related patient safety incidents
Health and social care practitioners should explain to patients, and their family members or carers where appropriate, how to identify and report medicines‑related patient safety incidents
Organisations should ensure that robust and transparent processes are in place to identify, report, prioritise, investigate and learn from medicines‑related patient safety incidents, in line with national patient safety reporting systems—for example, the National Reporting and Learning System
Organisations should consider using multiple methods to identify medicines‑related patient safety incidents—for example, health record review, patient surveys and direct observation of medicines administration. They should agree the approach locally and review arrangements regularly to reflect local and national learning