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Found 168 results
  1. Event
    This Westminster conference will discuss the strategic priorities for tackling overprescribing in the NHS. It follows NHS England’s overprescribing review and subsequent Good for You, Good for Us, Good for Everybody action plan. Delegates will discuss what would be needed if the plan’s aims for systemic and cultural change are to be achieved, and priorities for the proposed Clinical Director for Prescribing. It will be an opportunity to discuss the future of medicines optimisation, opportunities for social prescribing, and measures to enable consistent delivery across the whole population and to expand the workforce to deliver non-medical treatments where possible. Key areas for discussion include: culture change - including development of leadership and accountability around overprescribing at national and ICS level - key issues for the Clinical Director for Prescribing systemic change - the role of social prescribing - strategic priorities for medicines optimisation - practicalities of scaling up: funding, staffing, training, and engagement with patients patient-centred care - practical steps - involving patients with managing long-term conditions - building support and frameworks required for development research - sharing best practice and guidance - building the evidence base - developing understanding of the groups most impacted digital - the role of digital transformation in supporting patient-centred care and the ability to make more informed care decisions - improvements to patient records pharma - system-wide collaboration and industry transparency. Agenda Register
  2. Content Article
    This year's World Patient Safety Day, due to take place on Saturday 17 September 2022, will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. In this blog for the hub, Laurence Goldberg, an independent pharmaceutical consultant, looks at how we can reduce drug administration errors by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient.
  3. Content Article
    In this article, Dr Diane Ashiru-Oredope and Eleanor Harvey from the UK Health Security Agency identify the risks of prescribing and dispensing oral antimicrobials and consider how pharmacy teams can minimise antimicrobial resistance.
  4. Content Article
    In the UK, over 26% of adults take prescription medications and in the US the figure is around 66%. But up to 50% of patients fail to take their medications as prescribed. As healthcare steadily pivots towards digital health, Dr. Bertalan Meskó and Dr. Pranavsingh Dhunno ask how new technologies can improve medication management. In this article for The Medical Futurist, they look at the importance of empowering patients to reduce the risk of medication errors. They highlight five medication management technologies that could help patients improve their own medication safety: Smart pill dispensers which deliver audible and visual cues to remind patients to take medications at the right time Medication reminder apps which help manage medication regimens and can sync the data with a caregiver or doctor Digital therapeutics which support patients to make treatment decisions Digital pills which integrate tracking technology into pills themselves Telemedical platforms that allow patients to request advice or raise concerns with their doctors.
  5. Content Article
    The life expectancy of people with severe mental illness (SMI) is shorter than those without SMI, with multimorbidity and poorer physical health contributing to health inequality. Screening tools could potentially assist the optimisation of medicines to protect the physical health of people with SMI. The aim of this research from Carolan et al. was to design and validate a medicines optimisation tool (OPTIMISE) to help clinicians to optimise physical health in people with SMI.
  6. Content Article
    Medication errors are any Patient Safety Incidents (PSI) where there has been an error in the process of prescribing, preparing, dispensing, and administering, monitoring or providing advice on medicines. Medication errors can occur at many steps in patient care, from ordering the medication to the time when the patient is administered the drug. From April 1 2015 to 31 March 2020 NHS Resolution received 1,420 claims relating to errors in the medication process. Of those claims, 487 claims settled with damages paid, costing the NHS £35 million (excluding legal costs). NHS Resolution initial data for medication errors indicates that anticoagulants, opioids, antimicrobials, antidepressants, and anticonvulsants are the most common medications to be implicated in incidents.
  7. Content Article
    This leaflet produced by the Irish Health Services Executive (HSE) provides a central place for patients to record information about their medications. It acts as a reference point for patients to use when discussing their medications with a healthcare professional and includes a reminder of the Know, Check, Ask campaign, aimed at reducing medication errors in the community.
  8. Content Article
    Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. In recognition of this, in 2017 the World Health Organization (WHO) launched the Third WHO Global Patient Safety Challenge: Medication Without Harm, aimed at improving medication safety. This article provides information and resources related to the Challenge.
  9. Content Article
    Earlier this year in March, a nurse from Vanderbilt University, RaDonda Vaught, was found guilty of criminally negligent homicide and gross neglect of a patient. In 2017, Vaught gave 75-year-old Charlene Murphey the incorrect medication. Murphey died as a result. Charlene Murphey’s tragic death highlights the failures of healthcare organisations and their leadership to be trustworthy as well as a fractured and weakened accountability system for patient safety in the United States.
  10. Content Article
    On the 21 July 2022 NHS Resolution’s Safety and Learning team, in partnership with the National Infusion and Vascular Access Society, hosted a virtual forum on extravasation injury claims. The intention of this event was to raise awareness of these injuries and help spread learning and process review across health providers.
  11. Content Article
    Health systems currently present a great degree of complexity, which provides risks to patients related to healthcare, and the possibility of incidents with or without harm. Patient safety culture highlights the need to investigate, analyse, and mitigate incidents to reduce risks to the patient. Medication errors have a high potential to do harm in paediatric hospital routines and most of them are preventable. The objective of this study was to describe a severe drug-related adverse event and present the root cause analysis and implemented improvements.
  12. Content Article
    NHS Resolution received 172 claims relating to anti-infective medications between 1 April 2015 until 31 March 2020. Anti-infective medications include antibiotics, antivirals and antifungals. The analysis in this leaflet focuses on closed claims that have been settled with damages paid and concern an element of the prescribing process: prescribing, transcribing, dispensing, administering and monitoring. Claims concerning a failure to recognise that an anti-infective was indicated have not been included within the analysis.
  13. Content Article
    This blog on the NHS England website looks at how Written Medicine, a service that provides bilingual medication information, is helping to reduce healthcare inequalities and medical errors in London. Written Medicine’s software allows pharmacies and hospitals to translate and print medication information, instructions and warnings. Drawn from a dataset of 3,500 phrases, printed labels are available in fifteen different languages. The bilingual labels help patients take ownership of their treatment, giving them a better understanding of how to take their prescribed medication. The solution is helping to reduce errors, improve medication adherence and enhance patient safety and experience. The blog also looks at the experience of London North West University Healthcare NHS Trust (LNWH) using Written Medicine. A 2019 audit showed that the service was valued by patients and highly successful in increasing medication adherence through empowering patients.
  14. Content Article
    Laurence Goldberg, an independent pharmaceutical consultant, discusses the effectiveness and also the potential for harm of unit-dose medicines distribution.
  15. Content Article
    This year World Patient Safety Day, due to take place on Saturday 17 September 2022, will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. This page links to resources to mark World Patient Safety Day from the official World Health Organization (WHO) website.
  16. News Article
    Hospitals must start using “smart” intravenous (IV) infusion technology to its full potential if they are to prevent dangerous drug errors, University of Manchester researchers have found. ‘Smart pumps’- which automatically calculate the dose and rate of different drugs before they are pumped into a vein - prevent potentially fatal errors by stopping the administration of the wrong rate. But according to the study published in BMJ Open Quality, though the technology probably saved the lives of 110 people in two Trusts over a year, it has largely failed to be adopted by hospitals. Though many IV pumps used in hospitals have a smart capability, most trusts do not utilise the functionality because they are difficult to configure and maintain. Smart pumps are usually configured by a pharmacist and checked by a consultant or senior nurse. Conventional pumps, however, are set by ward staff who calculate and input infusion rates themselves - increasing the risk of drug errors. The risks are illustrated by previous work from the Manchester team, who demonstrated that 1 in 10 IV drug administrations are associated with an error, and up to 1 in 10 of those were associated with harm. Read full story Source: University of Manchester, 1 August 2022
  17. Content Article
    In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the safety issues faced by people with diabetes in hospital settings. Reflecting on feedback from Twitter users with diabetes, she looks at why so many people with diabetes fear having to stay in hospital, and asks what the NHS and its staff can do to make it a safer, less stressful environment.
  18. News Article
    A nurse who recorded she had given medication to care home residents when in fact she had delegated the task to unqualified staff has been struck off. Adelaide Maloane was working a night shift at Somerleigh Court in Dorchester, Dorset, in August 2019 when the incident took place. Ms Maloane delegated giving 16 medicines to residents to an unqualified healthcare assistant at the home. The Nursing and Midwifery Council said Ms Maloane had "failed to acknowledge the seriousness of her misconduct and dishonesty and the implications of her actions for residents, colleagues and the reputation of the nursing profession". Read full story Source: BBC News, 21 July 2022
  19. Content Article
    This article discusses how medication safety can be improved in Canada. It explores the complexities of aging, what can go wrong with medication, 'Best Possible Medication Histories', the role of pharmacists and paramedics, engaging with patients and their families, and improving communication across the healthcare system.
  20. News Article
    The Food and Drug Administration will consider an application for the first birth control pill to be sold without a prescription. The application from HRA Pharma would seek to make Opill – an every day, prescription-only hormonal contraception first approved in 1973 – available over-the-counter. Such an approval from the FDA would allow people to purchase “the pill” without a prescription for the first time since oral contraceptives became widely available in the 1960s. The application will also cast oral contraceptives into a fraught political moment in the US. The US supreme court ended federal protection for abortion rights late last month, throwing into question the future of birth control. “This historic application marks a groundbreaking moment in contraceptive access and reproductive equity in the US,” said HRA Pharma’s chief strategic operations and innovation officer, Frédérique Welgryn. “More than 60 years ago, prescription birth control pills in the US empowered women to plan if and when they want to get pregnant.” Making birth control available without a prescription will “help even more women and people access contraception without facing unnecessary barriers”, said Welgryn, whose company has already submitted the application. Read full story Source: The Guardian, 11 July 2022
  21. Content Article
    Patients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. This systematic review in BMJ Quality & Safety aimed to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.
  22. Content Article
    Medication errors are a common issue within the care home sector, impacting on the health and wellbeing of residents as well as creating challenges for care home staff and managers. This report addresses the issue of medication safety in care homes in England. Through intense engagement with a representative sample of care homes and stakeholders involving an electronic survey, workshops and conversations, Patient Safety Collaboratives have sought to understand the reasons for medication errors and how these could be avoided in the future.
  23. Content Article
    In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents.
  24. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting. As its ‘reference case’, the investigation uses the experience of Kathleen, a 73 year old woman with type 2 diabetes who received two recognised overdoses of insulin while she was in hospital. On both occasions she became hypoglycaemic, received medical treatment, and recovered. Patient Safety Learning has published a blog reflecting on some of the key patient safety issues highlighted in this report.
  25. Content Article
    Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue causing trauma. This leaflet describes the risks posed by extravasation to patients, the extent of the problem in the NHS and what is currently being done to reduce the risk of avoidable harm. The leaflet sets out the action to prevent, recognise, treat and report extravasation which is urgently needed. It emphasises the importance of all suspected extravasation injuries being reported and investigated, with reviews undertaken to learn and take action to prevent harm to future patients.
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