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Improving the safety of patients prescribed clozapine

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NHS Midlands and Lancashire CSU’s Medicines Management and Optimisation Team collaborated with a local mental health trust to address the issue of inadequate documentation of clozapine, a high-risk medication, in primary care patient medication records. This posed significant risks to patient safety, including missed drug interactions, overlooked side-effects, and compromised transfer of care. The team aimed to improve the quality and safety of care for patients prescribed clozapine.


A comprehensive review of patient records was undertaken, and measures were implemented to address the issue. The team audited 220 patient records and added clozapine where it was absent. A safety protocol was developed and integrated into the prescribing systems of all local GP practices to alert clinicians about the potentially fatal complications of clozapine treatment.

The team collaborated closely with the mental health trust, information technology colleagues, clinical pharmacists, and prescribing system specialists to ensure accurate documentation and effective implementation of the safety protocol.


The project implementation had the following outcomes:

  • Enhanced patient safety: Initially, 36% of patients prescribed clozapine lacked proper documentation in their records. By including clozapine information for all 79 patients, the team achieved 100% visibility of clozapine prescriptions in primary care.
  • Correct medication positioning: All 220 patients had clozapine accurately positioned as a 'hospital only repeat' medicine, effectively preventing unintended primary care prescribing.
  • Improved awareness and management: Integrating the clozapine safety protocol into the prescribing systems of 50 GP practices led to better awareness and management of clozapine-related side effects and drug interactions.
  • Enhanced collaboration: This implementation led to improved collaboration and communication between the team and the local mental health trust, resulting in the adoption of similar initiatives for other high-risk medications.
  • Reduced risks: The project significantly decreased risk associated with care transfer, inadvertent prescribing errors and missed side effects of clozapine treatment.
  • Quantifiable value: The team assessed the value of these safety improvements at £11,297 for the financial year, in terms of lowered risk of harm and prevention of hospital admissions.

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The prescribing system safety protocol is certainly noticeable and has alerted me to consider the potentially fatal side-effects of clozapine treatment when I am reviewing my patients.
GP Partner
This collaborative initiative enhances the care provided to patients prescribed clozapine by up skilling primary care colleagues, bolstering key safety messages at the time of prescribing and ensuring patients in need are escalated to specialist mental health services in a timely fashion.
Mental Health Trust, Associate Director of Pharmacy