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Content ArticleThe Digital Medicines Transformation Portfolio aims to use digital technologies to make prescribing, dispensing and administering medicines everywhere in Wales, easier, safer and more efficient for patients and professionals. It brings together the programmes and projects that will deliver a fully digital prescribing approach in all care settings in Wales. This video outlines the different elements of the portfolio that will be introduced across primary and secondary care, including the Shared Medicines Record, which will store information about a patient's medications all in one place.
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Content ArticleA patient advocate is someone who, with the patient’s consent, supports that person in their interactions with healthcare providers. This support can be provided during visits to a doctor's office, on a trip to the pharmacy, during a hospital stay, or when a nurse comes to visit in the home. An advocate can be a family member or friend, or it might be someone outside the patient's circle who offers or agrees to take on this role. An advocate can help in a variety of ways, including sharing information as needed and helping the patient understand and remember details from the visit. Having an advocate present, especially for individuals who find it hard to speak for themselves, can help prevent medication errors.
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News ArticlePharmaceutical giants are pouring tens of millions of pounds into struggling NHS services – including paying the salaries of medical staff and funding the redesign of patient treatment – as they seek to boost drug sales in the UK, the Observer can reveal. The spending is revealed in an investigation that lays bare the growing role of Big Pharma in the UK’s health sector, with analysis of more than 300,000 drug company transactions since 2015 showing a surge in spending on activities other than research and development (R&D). Payments to UK health professionals and organisations, including donations, sponsorship, consultancy fees and expenses, reached a record £200m in 2022, excluding R&D with companies seeking to promote lucrative drugs for obesity, diabetes and heart conditions among the biggest spenders. The rise in spending raises concerns about the growing influence of pharmaceutical companies in the NHS as it reaches its 75th anniversary milestone. Amid record pressure on services, drug giants say closer collaboration can help deliver major benefits to patients. NHS England said collaborations with industry helped patients “benefit from faster access to innovative treatments” and that it was “not unusual for industry to provide funding to support service delivery in areas such as improving cardiovascular health, tackling infectious disease or rolling out innovative cancer therapies”. It added that “strict safeguards” were in place for managing conflicts of interest. Read full story Source: The Guardian, 8 July 2023
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News Article
Weight-loss jabs investigated for suicide risk
Patient Safety Learning posted a news article in News
Europe's drugs regulator has told BBC News it is conducting a review of some weight-loss jabs after being alerted to a possible link to thoughts of suicide and self-harm among users. Member state Iceland notified the European Medicines Agency after seeing three cases. The safety assessment will look at Wegovy, Saxenda and similar drugs, such as Ozempic, that help curb appetite. Product leaflets already list suicidal thoughts as a possible side effect. An EMA official said: "The review is being carried out in the context of a signal procedure raised by the Icelandic Medicines Agency, following three case reports. "A signal is information on a new or known adverse event that is potentially caused by a medicine and that warrants further investigation. "The case reports included two cases of suicidal thoughts - one following the use of Saxenda and one after Ozempic. "One additional case reported thoughts of self-injury with Saxenda. "The EMA will communicate further when more information becomes available." Read full story Source: BBC News, 10 July 2023 -
News Article
Patient dies and three hospitalised in Sciensus chemotherapy incident
Patient Safety Learning posted a news article in News
A cancer patient has died and three others have been hospitalised after they were administered unlicensed versions of chemotherapy by Sciensus, a private company paid millions by the NHS to provide essential medication. Three health regulators have launched inquiries into the incident, according to people familiar with the matter. It was caused by an issue at the firm’s medicines manufacturing unit. In a statement, Sciensus confirmed an “isolated incident” had “affected four patients” and that it was “deeply saddened” that one of them had died. Sciensus offered its “sincere condolences” to the family and friends of the patient who died, and is conducting a thorough investigation, it added. The four patients received unlicensed versions of cabazitaxel, a licensed chemotherapy used to treat prostate cancer. The versions administered to the patients differed from the licensed product and therefore were considered unlicensed medicines. Sciensus is required to comply with official standards to ensure the quality of the products it produces and the protection of public health. Breaches of these standards can result in the MHRA suspending or removing a company’s licence. “Patient safety is our highest priority,” said Dr Alison Cave, the MHRA’s chief safety officer. “We are urgently investigating this issue and we will take any necessary regulatory measures to ensure patients are protected." Read full story Source: The Guardian, 7 July 2023 -
News Article
Sarms: Illegal muscle drugs sold in UK shops, BBC finds
Patient Safety Learning posted a news article in News
"Dangerous" muscle-building drugs are being sold illegally in shops around the UK, a BBC investigation has found. The substances, known as Sarms, can cause erectile dysfunction, mood swings and liver problems, doctors warn. Secret filming by the BBC found they were widely available in shops that sell bodybuilding supplements as well as online. Responding to the findings, the Royal Pharmaceutical Society (RPS) called for the law to be tightened. Sarms - which stands for selective androgen receptor modulators - are body-enhancing drugs that mimic the effects of anabolic steroids, which increase muscle mass and strength. Originally developed as an experimental drug to treat muscle-wasting conditions, they have become popular with gym-goers on social media who want to build muscle and lose fat. Read full story Source: BBC News, 7 July 2023 -
Content ArticleFollowing an extensive process of internal and external engagement, the Medicines and Healthcare products Regulatory Agency has published their corporate plan for the next 3 years. Their priorities are: Maintain public trust through transparency and proactive communication Enable healthcare access to safe and effective medical products Deliver scientific and regulatory excellence through strategic partnerships Become an agency where people flourish alongside a responsive customer service culture.
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Content ArticleUS endocrinologist Richard Plotzker shares a recent experience of buying over-the-counter medication from a grocery store. When he opened the outer packaging, the blister packs were empty apart from one pill in each being resealed by scotch tape. Richard called the manufacturer and returned the medication for investigation. He describes how the incident highlights the need to be vigilant about any unusual appearance in the packaging of medication.
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Content ArticleVideo of the 10th Annual World Patient Safety, Science & Technology Summit presentations. The event fostered a high-level exchange of ideas and initiatives to improve global patient safety with expert speakers and panelists, inspiring messages from hospital executives, and the sharing of tragic patient stories. The programme ignited further momentum to reach ZERO harm. You can view all the speaker presentations by clicking on the image below. There is also a link to the Patient Safety Movement Foundation website with all the presentations at the end of the page.
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Content ArticleMaking data on medical interventions easier to collect and collate would increase the odds of spotting patterns of harm, according to the panel of a recent HSJ webinar. When Baroness Julia Cumberlege was asked to review the avoidable harm caused by two medicines and one medical device, she encountered no shortage of data. “We found that the NHS is awash with data, but it’s very fractured,” says Baroness Cumberlege, who chaired the Independent Medicines and Medical Devices Safety Review and now co-chairs the All-Party Parliamentary Group which raises awareness of and support for its findings. It was a challenge on which Professor Sir Terence Stephenson had cause to deeply reflect back in 2014. That was the year in which he was asked to chair an independent review of medical devices, following concerns about the safety of metal-on-metal hip replacements and PIP silicone breast implants. “The NHS stepped up to the plate really quickly and said: ‘Even if it’s a private hospital that put this in, we will take it out to protect your safety,’” recalled Sir Terence, now Nuffield professor of child health at Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England. “But the big problem was they couldn’t identify who had which implants. No doubt somebody somewhere had written this down with a fountain pen and then someone spilt the tea over it and the unique information was lost.”
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News Article
Sight-saving drug to be offered to premature babies, announces NHS
Patient Safety Learning posted a news article in News
Premature babies across England will be offered a sight-saving drug, the NHS has announced. Retinopathy of prematurity (ROP) is an eye disease that can occur among babies who are born early or those born with a low birth weight. The NHS routinely screens these babies for the condition, which affects blood vessels in the retina, creating damaging scar tissue and causing blindness. Traditionally the condition is treated with laser eye surgery but some babies are too unwell or fragile to have the treatment. Now the NHS is offering new “life-changing” drug ranibizumab to babies with ROP across England who are unable to receive traditional treatment. NHS chief executive Amanda Pritchard said: “The impacts of vision loss can be absolutely devastating, particularly for children and young people, so it’s fantastic that this treatment will now give families across the country another life-changing option to help save their child’s precious sight." Read full story Source: The Independent, 4 July 2023 -
News Article
Men on epilepsy drug may have higher risk of children with disabilities
Patient Safety Learning posted a news article in News
Men who take the epilepsy drug sodium valproate could beat increased risk of having children with disabilities, research has found. A study ordered by the European Medicines Agency (EMA) has suggested a link between fathers taking the drug three months before babies are conceived and a small increased likelihood that the children will have neurodevelopmental disorders. The drug manufacturer Sanofi has not published the full results, leading to confusion among patients and doctors. Sodium valproate, sold in the UK as Epilim, is prescribed to treat epilepsy, bipolar disorder and migraines. It is known to cause deformities in one in ten babies exposed to it in the womb because their mothers are taking the drug. Four in ten babies suffer developmental delays. Read full story (paywalled) Source: The Times, 2 July 2023 -
Content ArticleMedication nonadherence - when patients don’t take their medications as prescribed - is unfortunately fairly common, with research showing that patients don’t take their medications as prescribed about half the time. The phenomenon has added consequences for patients with chronic disease. When this is the case, it is important for physicians and other health professionals to understand why patients don’t take their medications. This will help teams identify and improve patients’ adherence to their medications. This article by AMA, highlights eight reasons why patients don't take their medications.
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Content ArticlePatients often have multiple providers involved in their care. On the one hand, patients are able to receive specialty care to help manage multiple, complex medical conditions. On the other hand, such fragmentation in care may lead to medication errors from inaccurate or incomplete patient medication lists. As stewards of their patients' care, it is essential that primary care providers take steps to review and reconcile each patient's medication list to avoid errors or adverse drug events, and organisational leaders must ensure that systems are in place to support these efforts.
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Content Article
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This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 9 June 2023. At this meeting, members of the Network were joined by Dr Henrietta Hughes, Patient Safety Commissioner for England. The PSMN is an informal voluntary network for patient safety professionals in England. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out about the network. -
Content ArticleThe extent to which postintensive care unit (ICU) clinics may improve patient safety for those discharged after receiving intensive care remains unclear. This observational cohort study from Karlick et al., conducted at an academic, tertiary care medical centre, used qualitative survey data analysed via conventional content analysis to describe patient safety threats encountered in the post-ICU clinic. For 83 included patients, safety threats were identified for 60 patients resulting in 96 separate safety threats. These were categorised into 7 themes: medication errors (27%); inadequate medical follow-up (25%); inadequate patient support (16%); high-risk behaviours (5%); medical complications (5%); equipment/supplies failures (4%); and other (18%). Of the 96 safety threats, 41% were preventable, 27% ameliorable, and 32% were neither preventable nor ameliorable. Nearly 3 out of 4 patients within a post-ICU clinic had an identifiable safety threat. Medication errors and delayed medical follow-up were the most common safety threats identified; most were either preventable or ameliorable.
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Content ArticleAn evidence review into the scale of the prescribed drug dependence and withdrawal problem in England published by Public Health England (PHE) in 2019 called for support for patients experiencing withdrawal symptoms, including a national 24 hour helpline and associated website. These calls have since been echoed in a recent BBC Panorama episode and other media accounts, but despite the evidence reviews, media interest and public awareness, nothing has changed. This open letter to the Government published in the BMJ calls for specialist NHS services to support patients harmed by taking prescription medications. Signed by healthcare professionals, it highlights that there are still almost no NHS services to support patients who have been harmed by taking medicines as prescribed by their doctor, such as antidepressants and benzodiazepines. The signatories believe that the NHS has a clinical and moral obligation to help those who have been harmed by taking their medication as prescribed, and are urgently calling upon the UK Government to fund and implement withdrawal support services.
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News Article
NI’s £800m use of prescribed medicines higher than anywhere else in UK
Patient Safety Learning posted a news article in News
Northern Ireland’s chief pharmaceutical officer has said that the use of prescribed medicines and the associated costs remains too high, exceeding £800m a year. In a blog to reflect on the 75th anniversary of the NHS, Professor Cathy Harrison added that medicine costs in NI are the second largest single investment made in the health service, after staff. “The average number of prescription items a year is 21 per person, at a cost of £227. This cost is the highest in the UK and the volume of prescription items is still rising each year,” she said. “There is an uncomfortable truth that manifests in the prescribing data for medicines. In Northern Ireland, we continue to use more of almost every type of medicine than other parts of the UK. “That includes more antibiotics, more painkillers, more baby milks, more nutritional supplements, even more oxygen.” Read full story Source: Belfast Telegraph, 27 June 2023 -
News ArticleA warning has been made over the possible side effects of a common NHS antibiotic by a coroner after a newly retired senior doctor died by suicide. "Respected and experienced" consultant cardiologist Robert Stevenson had no history of depression or mental health problems before he started a course of ciprofloxacin. But just over a week later, the 63-year-old went for a walk and messaged his wife to tell her he had left a note under his pillow. He was later found dead in a nearby wood. The note he had left was said to be "uncharacteristically confused and illogical" with "baseless concerns" that he might have AIDS after taking an online HIV tester kit, an inquest heard. The hearing was told Dr Stevenson hadn't been told about a "potential rare link" to suicidal behaviour in patients who took the drug, as this wasn't in line with medical guidance. Now, coroner Martin Fleming issued a warning to highlight the risk of taking the antibiotic, which is prescribed by the health service for serious conditions. Read full story Source: The Mirror, 20 June 2023
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Content ArticleMr Stevenson was a 63-year-old man who was a very respected and experienced Consultant Cardiologist and General Physician at Huddersfield Royal Infirmary, who resigned from his post in May 2022 to enter full retirement. On 6 May 2022 he was referred to the urology department for the investigation of possible prostate cancer, when a decision was also made to consult a private Consultant Urologist. In order to relieve his symptoms of prostatitis and to make him ready for an investigative biopsy, he was prescribed ciprofloxacin on the 19 May. He had no previous history of depression or mental health problems. Subsequently on the morning of 30 May 2022, Mr Stevenson left his home address on his own for his usual walk. He had not previously given any indications to his family for them to be concerned for him. At approximately 12.30pm his wife received a Facebook message from Mr Stevenson to indicate that he had left a note under the pillow of his bed. The note was found to be uncharacteristically confused and illogical given his reference to his baseless concerns that he may have developed AIDs after taking a HIV tester kit he had previously bought on line. Mr Stevenson was found hanging nearby. Upon the arrival of the paramedics, although resuscitative attempts were made, it was confirmed that he had passed away. During the inquest the coroner was referred by Mr Stevenson’s treating urologist to published literature relating to ciprofloxacin and quinolone antibiotics and a potential rare link to suicide behaviour in patients; although it remained unclear that he was suffering from this side effect, it remained possible for this to be the case.
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Content ArticleThis stocktake by NHS Confederation highlights insights from medicines optimisation forums on the experience of ICS medicines optimisation so far: the opportunities that exist, the barriers experienced, the support that is needed, and what the vision for medicines optimisation could achieve.
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Content ArticleThe widespread adoption of effective hybrid closed loop systems would benefit people living with type 1 diabetes by improving the amount of time spent within target blood glucose range. Hybrid closed loop systems (also known as 'artificial pancreas' typically utilise simple control algorithms to select the best insulin dose for maintaining blood glucose levels within a healthy range. Online reinforcement learning has been utilised as a method for further enhancing glucose control in these devices. Previous approaches have been shown to reduce patient risk and improve time spent in the target range when compared to classical control algorithms, but are prone to instability in the learning process, often resulting in the selection of unsafe actions. This study in the Journal of Biomedical Informatics presents an evaluation of offline reinforcement learning for developing effective dosing policies without the need for potentially dangerous patient interaction during training.
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News Article
Antidepressants: Two million taking them for five years or more
Patient Safety Learning posted a news article in News
More than a quarter of patients on antidepressants in England - about two million people - have been taking them for five years, the BBC has found. This is despite there being limited evidence of the benefits of taking the drugs for that length of time. A doctor who runs an NHS clinic helping people off the pills says withdrawal symptoms can make it hard for some to stop taking their medication. Withdrawal guidance was updated in 2019, but he says little has changed. More than eight million people in England are on antidepressants - which are prescribed for depression, anxiety and obsessive compulsive disorder and other conditions. That's one million more people than five years previously, NHS prescribing figures show. The investigation also uncovered evidence that a leading drug company attempted 27 years ago to conceal possible withdrawal effects that one drug could cause. Read full story Source: BBC News, 19 June 2023 -
Content ArticleMedication error may occur for a variety of reasons. One of the most common sources of medication error is related to look-alike and sound-alike (LASA) drugs as well as the often-similar appearances of the vials. LASA medications are typically thought of as medications that are similar in physical appearance related to packaging as well as medications whose names are similar in spelling or in the phonetic pronunciation. Tricia A. Meyer looks at cases of LASA drugs and prevention techniques. She concludes that healthcare professionals, safety groups, and professional organisations should continue to work with manufacturers, regulators, and naming entities to explore opportunities to minimise the LASA risks for drugs that are either new to the market or in the pre-marketing stage. Further information on the hub Take a look at our Error traps gallery on the hub
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News Article
Menopause doctor says hormone scam endangers women's health
Patient Safety Learning posted a news article in News
A menopause doctor says scammers using her name to illegally sell testosterone online are damaging women's health. Dr Louise Newson, who founded Newson Health, has warned patients a website has stolen her brand and logo and is selling the sex hormone unlawfully. "We do not sell medication directly to anyone online," she adds. Testosterone is illegal to sell or supply without a prescription from a health professional and currently unlicensed in the UK for use by women. However, the National Institute for Health and Care Excellence (NICE) recommends it can be considered as a supplement for menopausal woman to treat low sexual desire if HRT alone is not effective. Dr Newson, whose private clinics operate in Stratford-upon-Avon, London, Southampton and Bournemouth, said medication was only prescribed after a consultation with a clinician. "As far as we are aware no Newson Health patients have fallen victim to this scam and we sincerely hope this remains the case," she said. The practice is working with relevant organisations to have the fraudulent website taken down, she added. Read full story Source: BBC News, 16 June 2023
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