Safe delivery of medicine: monitored dosage systems

An incident was shared with the Patient Safety Group in which a Monitored Dosage System (MDS) was dispensed by a community pharmacy, delivered to the home of a vulnerable patient and posted through their letterbox.

The vulnerable patient subsequently took all the medication in the MDS and required treatment in A&E. 

In response to the incident, the Patient Safety Group has developed a resource which encourages pharmacy teams to learn from such incidents and highlights best practice when delivering medicines.

The Patient Safety Group has developed broader guidance on the safe delivery of medication in a variety of situations. It is available here.