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Content ArticleA new Information Standard has been published by NHS Digital to support improved medication and allergy/intolerance information sharing across healthcare services in England.
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Better use of data for medication safety in hospitals
Kenny Fraser posted a topic in Medicine management
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NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks- Posted
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- Interoperability
- Precision medicine
- Start-Up
- Safety assessment
- Safety behaviour
- Safety management
- Improved productivity
- Medication - related
- Patient identification
- Patient safety strategy
- Policies
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- User-centred design
- Workforce management
- Information sharing
- Staff engagement
- Training
- Time management
- Allergies
- Deep vein thrombosis
- Falls
- Parkinsons disease
- Substance / Drug abuse
- Urinary tract infections
- Antimicrobial resistance (AMR)
- Benchmarking
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- Workload analysis
- NRLS
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Content ArticleFood allergy affects around 7-8% of children worldwide, or about two children in an average-sized classroom. As children spend at least 20% of their waking hours in school, it is not surprising that data show that 18% of food allergy reactions and 25% of first-time anaphylactic reactions occur at school. This report by the Benedict Blythe Foundations looks at the prevalence and seriousness of allergies in school-aged children, and the devastating consequences when things go wrong at school.
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Content ArticlePharmaswiss Česka republika s.r.o. and distributor Bausch & Lomb UK Limited is recalling all unexpired batches of Emerade 500 micrograms and Emerade 300 micrograms adrenaline auto-injectors (also referred to as pens) from patients. This is due to an issue identified during an ISO 11608 Design Assessment study where some auto-injectors failed to deliver the product or activated prematurely. Specifically, the 1-metre free-fall (vertical orientation) pre-conditioning resulted in damage to internal components of the auto-injector, leading either to failure to deliver the product or premature activation. This damage was not visibly apparent following the pre-conditioning but was evident only on subsequent functional testing. It is unclear what impact this has on auto-injectors in clinical use, however as a precautionary measure and owing to the inability to identify this issue before the auto-injectors are used, the auto-injectors are being recalled. Healthcare professionals should inform patients, or carers of patients, who carry Emerade 300 or 500 microgram auto-injector pens to obtain a prescription for and be supplied with an alternative brand. They should then be informed to return their Emerade 300 or 500 microgram pens to their local pharmacy.
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News Article
GPs to follow new digital standard for sending medicines and allergy information
Patient Safety Learning posted a news article in News
A new information standard has been developed for sharing digital information on medication and allergies across different parts of health and social care services. The standard, which aims to reduce medicines errors comes into effect this month. NHS and social care organisations will have to show compliance by March 2023. GP practices, hospitals, mental health trusts, pharmacists, community teams and residential care homes will all have to meet the standard when transferring medication and prescription information between teams. The standard will be particularly helpful in reducing medication errors when patients transfer between care locations NHS Digital said. Having specific requirements in place for how medicine and allergy information is transferred will also provide clinicians with a more detailed and consistent source of medicines related information across all care settings and allow them to obtain medicines information more quickly and efficiently, they added in a document outlining the changes. The standard defines how the send and receive messages involving medicines information are constructed, and how the data within is structured so that it is machine-readable when sent between different IT systems. Dr Simon Eccles, deputy CEO of NHSX and national chief clinical information officer said: ‘This new standard will make medicine prescribing safer for patients and easier for clinicians, reducing errors in prescription and improving the monitoring of medications that can cause harm. ‘This is the result of a true collaborative effort between NHSX, NHS Digital, industry and the frontline that will make a real difference to the care and support local clinicians can provide to their patients." Read full story Source: Pulse, 28 October 2021- Posted
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News ArticleThere is a “lack” of NHS services available to people with allergies, a group of MPs has said. Despite increasing rates of hospital admissions for severe allergic reactions – also known as anaphylaxis – allergy services “have largely been ignored”, the All Party Parliamentary Group for Allergy said. The group warned allergies are “poorly managed” across the health service due to a “lack of training” and only a small number of allergy experts. “This mismatch has continued despite millions of patients having significant allergic disease,” it said. In its latest report, which is to be delivered to Government on Wednesday, MPs said there are 20 million people in the UK who are living with allergic disease, including five million whose illness is severe enough to need specialist care. “Yet our allergy services remain inadequate, often hard to access and are failing those who need them the most,” the report adds. The group made a series of recommendations including: devising a “national allergy plan” to address problems; expanding the specialist workforce and ensuring all GPs get training in how to deal with allergies. Read full story Source: ITV News, 27 October 2021
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News ArticleA nurse from scandal-hit Shrewsbury and Telford Hospital ordered a pregnant woman to take medication she was allergic to. Christine Speake, who had worked in the NHS for almost 40 years as a midwife and nurse, has been struck-off the Nursing and Midwifery Council (NMC) register after a tribunal heard she told the mother to “just take it” and then tried to cover-up her mistake after the woman suffered a reaction. The NMC hearing was told the 11-week pregnant patient and her unborn child could have died after being prescribed the Buscopan by a junior doctor to treat severe nausea and vomiting in January 2019. The woman – named only as 'Patient A' – was given the drug by Speake despite her allergy being included in her medical records. Speake was employed as a sister on the gynaecology ward at the Princess Royal Hospital. When the mother questioned what she was being given, Speake, who has worked as a midwife and nurse since 1985, snapped "just take it". The panel heard Patient A then had a violent reaction and broke out in a rash and started vomiting. But Speake, who realised her mistake, then failed to tell her colleagues in a bid to “cover up” what she had done and later resigned, the NMC tribunal heard. Read full story Source: The Independent, 26 October 2021
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News ArticlePeople with allergies and pregnant women can now be given the country’s two approved COVID-19 vaccines, the medical regulator said on Wednesday. Previous advice from the Medicines and Healthcare products Regulatory Agency (MHRA) said people with a range of allergies to food and medicines should not be given the Pfizer vaccine. Dr June Raine, the MHRA’s chief executive, said growing evidence from a pool of at least 800,000 people in the UK and around 1.5 million people in the US who have had the vaccine has "raised no additional concerns". This, she continued, "gives us further assurance that the risk of anaphylaxis can be managed through standard clinical guidance and an observation period following vaccination of at least 15 minutes. Read full story Source: The Independent, 30 December 2020
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News ArticleThe UK’s drug regulator has warned that people with have a history of “significant” allergic reactions should not receive the Pfizer-BioNTech vaccine. The Medicines and Healthcare products Regulatory Agency (MHRA) issued the warning after two NHS staff members who were administered with doses on Tuesday both suffered an allergic reaction. NHS England said all trusts involved with the vaccination programme have been informed. Dr June Raine, chief executive of the MHRA, said the regulatory body was examining the cases. “We know from the very extensive clinical trials this wasn’t a feature," she told a parliamentary committee on Wednesday. "But if we need to strengthen our advice now that we’ve had this experience in the vulnerable populations - the groups that have been selected as a priority - we get that advice to the field immediately.” Read full story Source: The Independent, 8 December 2020
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Content ArticleThis study in the International Journal of Environmental Research and Public Health examines the demographic, clinical and socioeconomic factors associated with diagnosis of Long Covid in children aged 5 to 18 years. The authors conducted a population-based cross-sectional study using data from 20,601 children living in Israel who tested positive for Covid between 1 February 2020 and 30 June 2021. They found several variables associated with the development of Long Covid, including: the severity of acute infection being hospitalised recurrent acute infection ADHD diagnosis chronic allergic rhinitis chronic urticaria. The authors call for heightened clinical awareness that Long Covid can be present in children, and highlight that this should affect public health policy because of Covid-19's long-term health impacts.
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Content ArticleThe Patient Safety Authority has put together information and tips for patients on a range of topics.
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Content ArticleThe National Institute for Health and Care Excellence (NICE) has released updated guidance which says that healthcare professionals should now prescribe those people with severe allergies two Adrenaline auto-injectors (AAIs) when discharging patients from hospital, and patients should always carry two devices with them.
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Content ArticleThe latest figures from NHS Digital show the number of hospital episodes in England with a primary diagnosis of anaphylaxis increased from 5,497 in 2018-19 to 5,517 in 2019-20. Previous figures have shown the number of cases of children hospitalised with severe allergic reactions in England has increased by 72 per cent over the last six years. Overall, including adults, there has been a 34 per cent rise in admissions over the same period. Figures from 2019 reveal wide regional differences among children admitted to hospital with anaphylaxis. The health region with the highest increase is London where the number of cases has risen by 167% from 180 in 2013-14 to 480 in 2018-19. Among those ten and under, the increase is a staggering 200 per cent. Natasha Allergy Research Foundation (NARF) has renewed its call for the Government to appoint an ‘Allergy Tsar’ to co-ordinate and take steps to make sure people with allergies get the treatment and care they need. NARF first called for the appointment of an ‘Allergy Tsar’ earlier this year following the inquest of Shante Turay-Thomas, 18, who died in 2018 from anaphylaxis after eating hazelnut.
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Content ArticleA deep learning algorithm accurately identified allergic reactions in hospital patient safety reports, which could help providers avoid medical errors and improve event surveillance, according to a study from Yang et al. published in JAMA Network Open. Allergic reactions – to medications, foods, and healthcare products – are becoming increasingly common in the US. Researchers noted that up to 36% of patients report drug allergies, and 4-10% report food allergies. Patients in healthcare settings are at particularly high risk of developing an allergic reaction, and it’s critical that providers are able to quickly detect and monitor these events. Results of this study suggest that deep learning can improve the accuracy and efficiency of the allergic reaction identification process, which may facilitate future real-time patient safety surveillance and guidance for medical errors and system improvement.
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Prevention of Future Deaths report: Karanbir Cheema
PatientSafetyLearning Team posted an article in Coroner reports
On 28 June 2017, 13 year-old Karanbir Cheemer was at school when another pupil threw a small piece of cheese at him. He was known to be allergic to cheese and he went into anaphylactic shock. Karanbir later died. In this report, senior coroner ME Hassell, highlights a number of patient safety concerns relating to his death and calls for action to prevent future deaths.- Posted
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Content ArticleShanté Turay-Thomas, a young woman who had a nut allergy, died of an acute anaphylaxis after eating hazelnuts on 18 Spetember 2018. In this report, senior coroner ME Hassell, highlights 20 'matters of concern' surrounding her death and calls for action to be taken for future deaths to be prevented.
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Content ArticleThe purpose of this study, published in the European Journal of Hospital Pharmacy, was to ascertain the views, beliefs and attitudes of hospital staff to incorrect penicillin allergy records in order to determine healthcare worker motivation for the implementation of a penicillin de-labelling antibiotic stewardship intervention at the study hospital. Findings showed that virtually all staff in this study, had encountered patients who believed themselves to be penicillin allergic, but felt the patient’s belief to be erroneous. Therefore, a penicillin allergy de-labelling intervention might be of benefit to ensure that patients who were not allergic were able to have the correct antibiotic.
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Safety Alert: Allergens issues – food safety in the NHS
Claire Cox posted an article in Allergies
Recently there have been several incidents relating to allergens in hospital food reported. The consistent themes are lack of information and/or communication regarding food allergens present in the food and/or details of the patient’s known food allergy. This alert contains actions for providers to take.- Posted
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Content ArticleIt is hypothesized that 90% of antibiotic allergies documented in patients’ health records are not actual, potentially life threatening, type I allergies. This distinction is important because such documentation increases antibiotic resistance, as more second-choice and broad-spectrum antibiotics are then used. Evidence is lacking regarding causes of this inappropriate documentation. To develop interventions aimed at improving documentation, the authors of this study, published in the Annals of Family Medicine, explored experiences of family physicians and pharmacists in this area. They found that the professionals involved perceived that antibiotic allergy documentation is seldom accurate, which may contribute to development of antibiotic resistance, increased costs, and decreased patient safety.
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Content Article
Making schools safer project
Claire Cox posted an article in Allergies
The Anaphylaxis Campaign is the only UK wide charity solely focused on supporting people at risk of severe allergic reactions.- Posted
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Content ArticleHealthcare professionals were made aware of alerts and letters issued about adrenaline auto-injectors in September and October 2019 by the Medicines & Healthcare products Regulatory Agency. This article provides a summary of recent advice issued to healthcare professionals, including information to provide to patients, to support safe use of adrenaline auto-injectors.
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Patient Safety Journal
Claire Cox posted an article in Suggest a useful website
The latest issue of the Patient Safety Journal is now out. US patient safety journal brought to you by the Patient Safety Authority, an independent agency of the Commonwealth of Pennsylvania. Each issue publishes original, peer-reviewed research and data analyses and also gives patients a voice. It's mission is to give clinicians, administrators and patients the information they need to prevent harm and improve safety.- Posted
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