Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.


Your browser is not accepting cookies. This means means you will have to log in each time you visit the site.
For the best experience of, please enable cookies.

By continuing to browse the site you are agreeing to our use of cookies. You can change your settings at any time.
Learn more

Trust commissions a workshop to enhance clozapine medicines management, improving processes and reducing clinical errors, and thereby improving patient safety


    • 67% of prescriptions for the clozapine clinic were inaccurate, out of date or had clinical errors
    • Patients had bloods taken as per Clozaril Patient Management System licensing requirements but no other monitoring occurred in the clinic
    • Over 50% of patients had not received an annual physical health check as per NICE guidance
    • Reduce clozapine prescribing errors and improve patient safety


    • Commissioned a rapid process improvement workshop to enhance clozapine medicines management
    • Representatives from within the Trust/primary care/private sector attended the workshop
    • Reconciled all clozapine prescriptions and other medicines the patient is receiving
    • Conducted physical observations on patients attending the clinic (BP/temp/pulse weight)
    • Invited patients to an annual physical health check and enabled bloods/ECG to be taken in the clinic


    • Improved processes and reduced waste, saving £5542 per year
    • Resulted in 100% of prescriptions for the clozapine clinic being accurate, complete and produced in a timely manner
    • Resulted in no clinical errors, improving patient safety
    • Resulted in all patients receiving an annual physical health check with associated monitoring and management plans

 * Please provide a brief outline of your work.

 A scoping exercise demonstrated that 67% of prescriptions for the clozapine clinic were inaccurate, incomplete, out of date, or had clinical errors. In the clinic patients had bloods taken as per CPMS licensing requirements but no other monitoring occurred. Over 50% of patients had not received an annual physical health check as per NICE guidance

Our work had two main aims;

1) To eradicate errors in prescribing of clozapine to zero.

2) To ensure that patients were monitored for side effects of clozapine and that physical health was monitored as per best practice

 * Please describe the actions you took to achieve your result.

 A four day rapid process improvement workshop was commissioned by the Trust medical director and facilitated by ‘CLIC’ Cumbria learning and improvement collaborative. The only ‘cost’ was the effective use of attendees time, energies and willingness to improve patient safety and care. The workshop was attended by all interested parties both within the Trust, primary care and the private sector (Lloyds pharmacy).

A patient who attended the clozapine clinic and a patient carer also attended. The workshop was also supported by representatives from Trust services including administration, information governance, and IT

During the workshop improvements in processes and reduction of waste identified £5542 pa of saving in addition to ten minutes for each patient appointment.

By streamlining some of our processes this enabled clinic staff to focus on patient care including introduction of physical observations (BP, temp, pulse, weight). Improvements in processes for production in prescriptions and managing blood test results released time for Trust pharmacists to attend the clinic to facilitate medicines management of clozapine and other medicines in the clinic. This included patient consultations regarding adherence and management of side effects.

These improvements in care would not have been achieved without the joint working of teams across boundaries and sectors that the RPIW facilitated. The workshop was supported by the Trust management team.

However, managers were only present for the beginning introductory and final ‘report out’ session. This meant that attendees could speak freely and honestly about problems but propagation of ideas and ways to overcome barriers were stimulated by ‘external’ CLIC facilitators.

However, actions and recommendations from the RPIW are supported by the Trust senior management and governance structures. The RPIW four day workshop was followed up by a 30, 60 and 90 day meeting also facilitated by CLIC. This ensured that actions and new processes were implemented and that momentum was not lost.

The RPIW workshop fostered new working relationships and an understanding of differing professional’s roles. This was a springboard to bringing about change which could not previously been realised. There has been a recognition that improvements in the medicines management of clozapine and monitoring of patients physical health is not a ‘one-off’ project but a continuous process. Teams now meet independently of ‘CLIC’ to review progress and are now working on the development of SOPs for the clinic and physical health monitoring. This work will be achieved by collaborative working with local GP

 * Please list the most significant results

 100% of prescriptions for the clozapine clinic are now accurate, complete and produced in a timely manner. There are now no clinical errors. All clozapine prescriptions have been reconciled with the patient and all other medicines the patient is receiving.

All patients receive physical observations when they attend the clinic. (BP, temp, pulse weight) and are asked specifically about the occurrence of constipation and smoking status. All patients have been invited to an annual physical health check.

A minority of patients have not attended a physical health check and have had bloods/ ECG taken opportunistically in the clozapine clinic.

 * Describe how your project has spread to other teams, departments or organisations

 Immediately and in order to minimise risks, prescriptions for clozapine throughout Cumbria were reviewed and reconciled with medicines prescribed by GPs. There are plans to replicate this work in the South of the County in Barrow where similar issues have been identified. Physical health monitoring of patients prescribed clozapine is now being embedded in policies for community mental health teams across Cumbria.

Our work in developing new processes for collaborative working with external pharmacy providers has been discussed with other NHS organisations in the North West. We all endeavour to prevent medication errors whilst embracing new ways of working. 

Key individuals

Siobhan Brewer