Why medicines safety matters

Medicines don't magically appear on shelves for purchasing or dispensing. Behind every tablet or injection is a complex system of NHS policies, procedures, pharmacy checks, and clinical decisions designed to keep patients safe. At the Medicines Optimisation Research Group (MORG) at the University of Bradford, we study how medicines are used in the real world, and how they can be used more safely and fairly. Our work looks at the whole system around medicines: from national NHS policies about prescribing and safety, to how hospitals, GP surgeries, and pharmacies put those policies into practice, and ultimately what that means for patients. By understanding where systems work well, and where they break down, we aim to help the NHS deliver safer care and ensure that medicines improve people’s health rather than cause harm. 

So why is this important? 

Medicines are by far and away the main thing that the National Health Service uses to improve our quality of life. After staffing costs, they are the second largest chunk of NHS costs - in 2024/25 the NHS England estimated that it spent almost £20 billion on medicines. This includes tablets, but also injectable medicines, inhalers, drops, ointments and fluids, chemotherapy, and advanced treatments for chronic diseases among others.   

However, access to medicines isn’t guaranteed even though we would consider it a basic human right - shortages of medicines within the UK continues to plague our pharmacies and undermine the quality of care that patients need, and healthcare professionals want to provide. The recent Medicines Security inquiry from the House of Lords Public Select Committee has challenged the UK government to consider raising the priority of medicines shortages to a national level, due to the negative impact of this issue on our society. There are many reasons why we struggle to access all the medicines we need in the UK, and we are not alone, as some of the shortages are global issues.  

Mistakes with medicines 

We all rely on medicines to make us live longer and better. One thing that research has shown in the last two decades is that if the health service is going to harm someone accidentally, the most common way this happens is through mistakes with medicines. In the UK it’s estimated there are almost 240 million medication errors every year in the NHS with 66 million potentially causing patients harm, and the costs are enormous – almost £100 million every year, and almost 200,000 additional days in hospital, recovering from the harm. Medication errors in primary care account for most of the costs of these and might be related to 700 people dying every year. In short, medication error creates crippling issues in the NHS. 

So how can we address this? 

The reality is that medication use and safety isn’t simple at all. Getting from a diagnosis to taking a tablet or receiving an injection is a complex process. This involves lots of different people, organisations, teams and places. For example, a patient visiting a local GP might need a blood test or an x-ray which means a visit to the local hospital. This hospital may then refer the patient on to a specialist who might work for a different hospital or clinic. All these places (surgery, hospital, clinic) have their own policies and guidelines, and individual clinicians have their own practices and habits. And then there are pharmacies, both in the community and in hospitals, whose teams play a critical role in ensuring that what’s dispensed is safe for each patient. Each step adds layers of complexity, and opportunities for errors if people and places don’t communicate effectively. The healthcare ecosystem, connecting these people and places, can be overwhelming to navigate.  

In the past, research to improve medication safety has focussed on getting people to follow rules and make “better” choices, often by making it harder to do the wrong thing. The NHS has invested billions in electronic prescribing that advises doctors on what drug to give for which diagnosis, and we have much better access to information on dosing and administration. Medicines reconciliation, a process of carefully checking a person’s full list of medications whenever they move between hospitals, clinics, or home, has also become a major priority, helping to catch errors before they cause harm. Yet these interventions haven’t had very much impact on reducing harm in patients, and in some cases have created new risks and dangers that weren't predicted.   

Healthcare systems aren’t built for safety, but for the most efficient way of getting a patient from diagnosis to treatment. There are multiple parts of the system that interact with and influence other parts of the system that we can’t see. Simply “following the rules” doesn’t make our NHS any safer because of these conflicts and impacts. The NHS is in crisis with services running at over 100% capacity and a workforce that is exhausted and demoralised by repeated crises including the COVID-19 pandemic and the struggling UK economy. We also have patients repeatedly tell us that they are not listened to by their healthcare providers.  

How we’re making a difference  

A core principle of our research is to include patients and carers in the design of the research that we conduct, and in developing the interventions to support medicines safety when they’re under our care. We have brought together hundreds of members of the public, and healthcare service users to consider how to improve their experiences with medicines and keep themselves safe. For example, we have co-designed practical tools to help people living with dementia maintain independence in managing their medicines, resources that have been tested by health and social care providers. We have also explored patients’ experiences of managing medicines when moving between care settings, such as between hospital and home, and worked with patients, carers, and healthcare professionals to design and test tools that better support people during these transitions. 

Alongside this patient-centred work, we examine how healthcare systems can improve medicines safety. Our research has highlighted the important role parents play in maintaining the safety of their children while in hospital, leading to the development of processes that formally involve them in care. We also use large-scale data to understand the scale and severity of intravenous medication errors and have developed international guidance on implementing technologies to reduce these risks. 

More broadly, our researchers are studying the resilience of the medicines supply system, including the growing challenge of medicines shortages and the pressures facing the UK medicines marketplace. Crucially, our work does not stop at research findings: we use this evidence to shape the education and training of healthcare professionals, engage the public in medicines safety, and contribute insights to national medicines strategy. 

Our philosophy is to work closely with patients and carers to understand and address the real challenges that affect medication use and safety from the patient’s perspective. Our work spans the life course, from birth through to later life, and contributes to improving healthcare practice, informing policy, and supporting better outcomes both nationally and internationally. As the NHS evolves to meet the aspirations of the 10-Year plan, with greater use of digital technologies, a growing emphasis on care delivered in the community, and the emergence of more personalised treatments, the Group continues to play a leading role in advancing research that improves the safe, effective, and equitable use of medicines. 

Photo: Members of the Medicines Optimisation Research Group (MORG) team (left to right): Prof Liz Breen, Dr Adam Sutherland and Dr Justine Tomlinson.

Authors

• Dr Justine Tomlinson is a pharmacist and assistant Professor whose research focuses on medication safety, in particular at transitions of care, and for older people.
• Dr Adam Sutherland is a pharmacist and associate professor who has worked with children and young people for most of his career. He is interested in how the involvement of young people and their families can make their care safer and better.
• Professor Liz Breen is a Professor of Health Service Operations whose research interests lie in healthcare systems improvement with a particular focus on the pharmaceutical supply chain and medicines security.