Cumbria Partnership Foundation Trust: Clozapine clinic patient safety improvement initiative

With analysis suggesting that 67 per cent of prescriptions for the trust’s clozapine clinic were inaccurate, incomplete or out of date – and that monitoring of patients on the anti-psychotic drug was sometimes lacking, particularly when it came to physical health – staff launched a project to eliminate errors and ensure consistent monitoring.

Sponsored by


The trust medical director commissioned a four day rapid process improvement workshop. Run by the Cumbria Learning and Improvement Initiative, it was attended by staff in primary care and community pharmacy as well as those within the trust, and by a patient and carer.

Workshop attendees identified a number of important changes to process, which are said to have freed up time for both clinic staff and for pharmacists.

As a result, all prescriptions for the clozapine clinic are now accurate, complete and timely; all patients receive physical observations when they attend the clinic; and all are now invited to an annual physical health check.

To read this entry in full visit HSJ Solutions.

Click here for more details on the HSJ Patient Safety Awards 2018.


  • The Walton Centre Foundation Trust: Reducing risks for women with epilepsy by increasing pre-conception counselling awareness – Highly commended
  • East and North Hertfordshire Trust: More power to the patient – system wide roll out of a pocket size diabetes medication sick day rule card
  • East Lancashire Hospitals Trust: Dedicated Ward Pharmacy (DWP)
  • Gateshead Health Foundation Trust: Reducing omitted doses of medicines due to medicines not available
  • Northumberland, Tyne and Wear Foundation Trust: Moving pharmaceutical care closer to the patient – technology supporting higher quality services
  • Royal Cornwall Hospitals Trust: Intravenous drug witnessing
  • South Sefton Clinical Commissioning Group: Medication review for patients at Aintree University Hospital
  • St George’s University Hospitals Foundation Trust: The impact of a medicines administration pharmacist on medicines administration and patient safety
  • St Helens and Knowsley Teaching Hospitals Trust: Medicines optimisation for patients with acute kidney injury