This programme includes our work with care homes, and healthcare staff who support them, to help reduce medication errors and our contribution to the development of a national plan to reduce the prescription of opioids.

The national Medicines Safety Improvement Programme has three aims:

  • To reduce medicine administration errors in care homes by 50% by March 2024.
  • To reduce harm from opioid medicines by reducing high dose prescribing (>120mg oral Morphine equivalent), for non-cancer pain by 50%, by March 2024
  • To reduce harm by reducing the prescription and supply of oral methotrexate 10mg by 50%, by October 2021 (nationally led)

We are working locally to address the first two of these.


A review by the University of York in 2018 estimated about 92 million medication errors occur each year in care homes – out of a total of 237 million. These not only impact on the health and wellbeing of residents but also add additional challenges for care home staff and managers to overcome.

In 2019, we sought views from local care homes and stakeholders via an electronic survey and direct conversations about the reasons for errors and how these could be avoided in the future. A KSS-wide report was developed based on the findings, which was fed into a national report for review by the Medications Safety Improvement Programme board. The national report is available here. It suggested that quality improvement interventions could be helpful in a number of practice areas to reduce medication errors.

As a result, we are working with a group of care homes and healthcare staff who support them, to explore the causes of medication errors and test ‘change ideas’ that could help to reduce them.

  • Safety huddles
  • Learning from incidents
  • Managing interruptions
  • 3-way communications (between care home, prescriber and dispensing pharmacy)

We are also promoting the role of safety champions in care home settings to support this and possibly other quality improvement work.

We will feed the results into a national review that will then develop a more structured programme to be rolled out after March 2022.

Opioid prescribing

There is no evidence for efficacy of high dose opioids, usually up to 120mg/day morphine equivalent in long term pain. Increasing opioid load above this dose is unlikely to yield further benefits but exposes the patient to increased harm. Despite this, PHE’s review (2019) shows that from 2017 to 2018, 5.6 million adults in England received opioid pain medicines (13% of the adult population).

A diagnostic exercise was carried out in March 2021 to identify effective interventions that lead to a reduction in opioid prescribing, which were submitted to the national team for review. This will contribute to a national report with more detail around the evidence base for successful opioid reduction interventions.

The ambition is to produce a national scale-up methodology and implementation plan for national spread of an effective opioid reduction intervention in chronic non-cancer pain.

For more information contact Sean Farran, Programme Manager:

KSS AHSN also has a Medicines Optimisation, programme, which you can find out more about here.