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Showing results for tags 'Adminstering medication'.
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Content ArticleMedicines play a crucial role in maintaining health, preventing illness, managing chronic conditions and curing disease. However, there is a growing body of evidence that shows us that there is an urgent need to get the fundamentals of medicines use right. Medicines use today is too often sub-optimal and we need a step change in the way that all healthcare professionals support patients to get the best possible outcomes from their medicines. Medicines optimisation represents that step change. It is a patient-focused approach to getting the best from investment in and use of medicines that requires a holistic approach, an enhanced level of patient centred professionalism, and partnership between clinical professionals and a patient. Medicines optimisation is about ensuring that the right patients get the right choice of medicine, at the right time.
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Content Article
Uppsala Monitoring Centre: VigiBase
Patient Safety Learning posted an article in Adverse interactions
VigiBase is the Uppsala Monitoring Centre (UMC)’s starting-point for the journey from data to wisdom about safer use of medicines and wise therapeutic decisions in clinical practice. It is the driving-force at the heart of the work of UMC and the WHO Programme. The purpose is to ensure that early signs of previously unknown medicines-related safety problems are identified as rapidly as possible. VigiBase is the unique WHO global database of individual case safety reports (ICSRs). It is the largest database of its kind in the world, with over 20 million reports of suspected adverse effects of medicines, submitted, since 1968, by member countries of the WHO Programme for International Drug Monitoring. It is continuously updated with incoming reports. -
Content ArticleMedication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. The Pennsylvania Patient Safety Reporting System (PA-PSRS) was queried and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020.
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Content ArticleThis study in BMC Medicine aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings. It is the largest meta-analysis to assess preventable medication harm to date. The authors found that one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Their results support the World Health Organization’s priority of detecting and mitigating medication-related harm and highlight other potential intervention targets that should be a priority research focus.
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Content ArticleThe United States is one of only three countries in the world that does not use the metric system. Yet, every single medication prescribed today is based on it. In addition to dosages based on the metric system, some doses are also very dependent on patient weight. These include blood thinners, certain antibiotics, chemotherapy agents, and many pediatric doses. The very young, very old, and people with certain medical conditions are at the highest risk of experiencing harm because their bodies are more sensitive to the effects of an error. Calculations made with incorrect weights can have devastating, if not fatal, consequences. Further reading Patient Safety Authority Department of Health: Final recommendation to ensure accurate patient weights
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Content ArticleThe objective of the national Medicines Safety Improvement Programme is to help patients get the maximum benefit from their medicines and reduce waste with an overarching aim to reduce medication related harm in health and social care, focusing on high risk drugs, situations and vulnerable patients. Each area of work in this programme intends to make medicines safety part of routine practice, ensure medicines use is as safe as possible and understand the patients’ experience. The national Medicines Safety Improvement Programme (MedSIP) is led by NHS England and Improvement’s patient safety team. The programme is delivered by the West of England Patient Safety Collaborative. Learn more about the West of England's MedSIP.
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Content ArticleNHS England and Improvement, in collaboration with the National Institute for Health and Care Excellence (NICE) and the Department of Health and Social Care (DHSC), has selected the first antimicrobial drugs to be purchased via the UK’s innovative ‘subscription-type’ payment model. Antimicrobial resistance (AMR) refers to the process by which microorganisms develop defences against antimicrobial drugs, enabling these microorganisms to adapt and become resistant to treatment. It’s a serious problem and has recently been identified as one of the World Health Organization’s top 13 global health challenges in the next decade. Without working antibiotics, routine surgery like caesarean sections or hip replacements will become too dangerous to perform, cancer chemotherapy will become prohibitively high-risk and certain infections will require long and complex treatment; or will no longer be treatable. Already, the microorganisms that cause many common diseases around the world – including tuberculosis, malaria, gonorrhoea, urinary tract infections and chest infections – can resist a wide range of antimicrobial medicines. Like all global challenges, leaders in the international community need to come forward and act on AMR, and the UK – with the NHS as the world’s largest single public health system – is taking the initiative. NHS England and Improvement project leads, Mark Perkins and David Glover, discuss this important step in tackling AMR.
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News ArticleNHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients. The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk. The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years. HSIB launched a national investigation into the problem of misplaced nasogastric (NG) tubes after a 26-year-old man had 1,450ml of liquid feed fed into his lungs in December 2018 after a bike accident. The patient recovered but the error was not spotted, even after an X-ray. Read full story Source: The Independent, 17 December 2020
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Content ArticleThe latest Healthcare Safety Investigation Branch (HSIB) report focuses on the life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients.
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EventDr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a group of experts, including pharmacists, anesthesiologists, respiratory therapists, family members, and nursing leaders, to explore the patient safety priorities of sedation, opioid therapy and respiratory depression. The group will discuss frequently encountered safety issues, explore organisational processes to reduce sedation safety events, and assess the role patients and family members can play in reducing harm. Register
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals. Smart infusion pumps are the latest generation of programmable devices that administer medication. They are seen as a way of improving safety as the smart functionality aims to prevent underdoses or overdoses – they are equipped with features such as alerts or alarms to help detect problems. The investigation was launched after one NHS Trust recorded three incidents where a smart infusion pump delivered an overdose of fentanyl, a powerful pain medication. The patients weren’t harmed as it was swiftly picked up, however it emphasised the new risks that come with introducing new technology and the potential for serious medication errors. The investigation focused on the barriers to implementing the technology effectively across the NHS, rather than on the technology itself.
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Content ArticlePharmacy teams should understand how to minimise the risk and likelihood of dispensing errors, including methods that can be used to evaluate existing processes, as well as how to deal with errors if they happen. This article from Phipps et al., in the Pharmaceutical Journal, builds upon the ideas proposed in ‘Understanding dispensing errors and risk’, and also proposes strategies and methods that should be considered for use in the pharmacy to manage the risk of dispensing errors.
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Content ArticleAs prescription numbers continue to increase, it is necessary to understand the dispensing errors that can occur and how they may happen. This article is the first of two articles from Phipps et al. on dispensing errors and risk. Reducing risk and managing dispensing errors will build on the ideas proposed in this article.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report sets out a case where a medication error with warfarin contributed to the death of a 79-year-old man. The patient had suffered a fall at home and had been admitted to hospital. An error on his chart whilst he was on the ward led to him receiving four or five doses of warfarin, which he did not normally take, before the error was spotted by a ward-based clinical pharmacist. The patient developed internal bleeding and deteriorated (due to several health reasons) and died 21 days after his first admission. Research published this year suggests that medication errors may directly cause around 712 deaths per year and indirectly contribute to 1,708. The report highlights the growing ageing population and that pharmaceutical care of older people can be complex. They are often taking multiple medications and are at the greatest risk of harm due to medicine-related errors.
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Content Article
NHS England: Support for prescribers
Patient Safety Learning posted an article in Medication administration
NHS England has commissioned the Specialist Pharmacy Service to provide prescribers with all the support they need to: Stop prescribing medicines which are not clinically-effective or cost-effective Provide clear information to patients to help them make meaningful choices and decisions about their treatment Help people to get the benefits they want from their prescribed medicines Encourage people to ‘self-care’ and choose not to take a medicine if they don’t really need one Take positive action to reduce waste so we stop throwing away so many medicines. -
Content ArticleMedication errors present a major public health burden and there is a need to optimise risk minimisation and prevention of medication errors through the existing regulatory framework. The European Medicines Agency (EMA) in collaboration with the EU regulatory network was mandated to develop regulatory guidance for medication errors, taking into account the recommendations of a stakeholder workshop held in London in 2013. This guidance is intended to support the implementation of the new legal provisions regarding the reporting, evaluation and prevention of medication errors and is intended mainly for the pharmaceutical industry and national competent authorities. Healthcare professionals (HCP) are expected to consult national clinical guidance on reducing the risk of medication errors.
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Content ArticleSorrel King was a 32-year-old mother of four when her eighteen-month-old daughter, Josie, was horribly burned by water from a faulty water heater in the family's new Baltimore home. She was taken to Johns Hopkins--renowned as one of the best hospitals in the world--and Sorrel stayed in the hospital with Josie day-in and day-out until she had almost completely recovered. Just before her discharge, however, she was erroneously injected with methadone, and died soon after. Sorrel's account of her unlikely path from grieving parent to nationally renowned advocate is interwoven with descriptions of her and her family's slow but steady road to recovery, and ends with a deeply affecting description of a ski trip they took recently. The sun is shining, her children are healthy, and they are all profoundly happy--a condition that Sorrel has learned to appreciate all the more for Josie. The book ends with a resource guide for patients, their families, and healthcare providers; it includes information about how to best manage a hospital stay and how to handle a medical error if one does occur.
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News Article
NHS hospitals ordered to remove drug after mistakes led to two baby deaths
Patient Safety Learning posted a news article in News
All NHS hospitals in England have been told to destroy a powerful medicine mistakenly used by staff because its packaging looks the same as another drug. A national safety alert was issued following several incidents, including two deaths of babies, in which patients were inadvertently given a dose of sodium nitrite – which is used as an antidote to cyanide poisoning – rather than sodium bicarbonate. The errors are thought to have been caused by similarities between the labelling and drug packaging used by manufacturers. Now hospitals have been told to check all wards and medicine storage areas for sodium nitrite and to destroy any of the unlicensed product. The drug should only be available in emergency departments and may have been supplied to medical wards by mistake. There are an estimated 237 million medication errors in the NHS every year – with a third linked to packaging and labelling. Read full story Source: The Independent, 9 August 2020 -
Content ArticleSodium nitrite has one licensed indication: as an antidote to cyanide poisoning. The Royal College of Emergency Medicine (RCEM) and National Poisons Information Service (NPIS) guideline recommends that it should be “immediately available in the emergency department”. Sodium nitrite can cause significant side effects and is categorised as ‘highly toxic’. Historically, sodium nitrite 30mg/ml has been an unlicensed product supplied in ampoules by ‘Specials’ manufacturers. However a licensed product, supplied as a vial, has been available since 2016. The National Reporting and Learning System (NRLS) identified two incidents where unlicensed sodium nitrite was inadvertently administered to premature babies instead of sodium bicarbonate 4.2%: one very premature baby died soon after this incident occurred and the other died after a period of neonatal intensive care. Hospitals have been given until 6 November to physically check all wards for the wrong drug and to destroy any unlicensed sodium nitrite supplies. This alert is an action for all acute trusts (children and adult).
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News Article
Chronic pain sufferers should not be given opioids, says medicines watchdog
Patient Safety Learning posted a news article in News
People with chronic pain that can’t be explained by other conditions should not be prescribed opioids because they do more harm than good, the medicines watchdog has warned. The National Institute for Health and Care Excellence (NICE) has said people should instead be offered group exercise, acupuncture and psychological therapy. In new draft guidance, NICE said most of the common medications used for chronic primary pain has little or no evidence to support their use in patients aged over 16. Its latest guidance comes amid concerns over the level of opioid use. In September last year a review by Public Health England found 1 in 4 adults have been prescribed addictive medications with half of them taking the drugs for longer than 12 months. NICE’s new draft guidance said some antidepressants should be considered for people with chronic primary pain but it said paracetamol, non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen, as well as benzodiazepines or opioids should not be given because of concerns they might do more harm than good. Read full story Source: The Independent, 4 August 2020 -
Content Article
Medication safety: "Know Check Ask"
Claire Cox posted an article in Resources for patients
Do you know your medicines? Do you keep a list? Can you describe and discuss your medicines with healthcare professionals and family when you want to? Keeping track of your medicines and communicating about them can be tricky as there can be so many details to remember. This is especially important if you have a healthcare appointment or are going to hospital. This "Know Check Ask" campaign website is here to help. Please click on the content below to learn more about taking medicines safely. -
Content ArticleThis webpage is to provide resources and expertise that will help UK pharmacists at the beginning of their careers to tackle the clinical problems that will confront them throughout their professional lives. This site is aimed at pre-registration and foundation level pharmacists in hospitals.
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Content ArticleThis YouTube video from nurse, Sophie Pig, aims to give you a better understanding of the 7 rights of medication administration. It is important to remember these 'rights' for every patient you encounter on a drug round.
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Content Article
Out-patient Parenteral Antibiotic Therapy (OPAT) is now a routine part of care in the UK following demonstration that it is safe and effective for patients and OPAT is now being actively promoted as part of the UK government’s stewardship initiatives. NHS North Tees and Hartlepool share their experience of redesigning their OPAT services. See the attachment below for details on the project. -
Content ArticleAn increasing number of studies show that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety and reliability may be compromised. This article from Rozich et al. discusses how standardisation may help to increase uniformity of practice, increase safety, and possibly reduce costs. Also described is an effort made by Luther Midlefort, Mayo Health System, to reduce variation by creating a system-wide protocol for insulin use. After six weeks, Luther Midelfort achieved a great reduction in the number of hypoglycaemic events as a result of standardised practices.
