Pharmacists have for many years claimed to have an interest in medication safety and many hospital pharmacies had introduced measures to ensure that medicines were used safely. Examples include steps to ensure that accidental overdoses were avoided and that selection or picking errors were prevented. Such measures were usually local and depended largely on the interests of individual pharmacists. In some hospitals medication errors were implicitly viewed as “a pharmacy problem” and not usually a matter of concern for senior managers. However, in 2001, when the National Patient Safety Agency (NPSA) was established – with its task to improve patient safety in the NHS in England and Wales – there was formal recognition of the role of the pharmacist in medication safety. When this body was formed, the special place of medicines in the patient safety arena was officially recognised and a senior pharmacist was appointed as Head of Medicines’ Safety. Early work by the NPSA showed that medication-related incidents were second most common type of adverse incident experienced by patients in the National Health Service (NHS). Since that time there have been numerous developments in this field and the role of the pharmacist has matured and strengthened. This article traces the growth of the medication safety movement and identifies some of the landmarks in its progress.
Key words: Patient safety, high-risk medicines, near-miss, pharmacy practice, injectable medicines