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News ArticleScientists and senior doctors have backed claims by France’s health minister that people showing symptoms of COVID-19 should use paracetamol (acetaminophen) rather than ibuprofen, a drug they said might exacerbate the condition. The minister, Oliver Veran, tweeted on Saturday 14 March that people with suspected COVID-19 should avoid anti-inflammatory drugs. “Taking anti-inflammatory drugs (ibuprofen, cortisone . . .) could be an aggravating factor for the infection. If you have a fever, take paracetamol,” he said. Jean-Louis Montastruc, Professor of Medical and Clinical Pharmacology at the Central University Hospital in Toulouse, said that such deleterious effects from NSAIDS would not be a surprise given that since 2019, on the advice of the National Agency for the Safety of Medicines and Health Products, French health workers have been told not to treat fever or infections with ibuprofen. Experts in the UK backed this sentiment. Paul Little, Professor of Primary Care Research at the University of Southampton, said that there was good evidence “that prolonged illness or the complications of respiratory infections may be more common when NSAIDs are used—both respiratory or septic complications and cardiovascular complications.” Read full story Source: BMJ, 17 March 2020
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News Article
Woman died after being given the wrong medication
Patient Safety Learning posted a news article in News
An 87-year-old woman died after her carers gave her the wrong medication, a coroner was told. Heather Planner, from Butler's Cross in Buckinghamshire, died at Wycombe Hospital on 1 April from a stroke. Senior coroner Crispin Butler heard three staff from Carewatch Mid Bucks had failed to spot tablets handed over by the pharmacy were for a male patient. Mr Butler said action should be taken to prevent similar deaths. A hearing in Beaconsfield on Thursday, where he issued a Prevention of Future Deaths report, followed an inquest in November. In the report he said he was told at the inquest that the carers from Carewatch Mid Bucks gave widow Mrs Planner the wrong medication four times a day for two and a half days. She suffered a fatal stroke because she did not receive her proper apixaban anticoagulation medication. Mr Butler said he would send his concerns to the chief coroner and the Care Quality Commission. He said there was no procedure in place to ensure individual carers read and specifically acknowledged any medication changes. Read full story Source: BBC News, 27 February 2020 -
News Article
Not enough pharmacists are aware of the yellow card scheme
Clive Flashman posted a news article in News
Every pharmacist must report adverse drug reactions using the yellow card scheme, says chair of the Community Pharmacy Patient Safety Group, Janice Perkins Polypharmacy, when different medications are used by an individual at the same time, is becoming increasingly common because people are living for longer and with multiple different illnesses. One study, published in 2018 by the Oxford University Press, found that over half (54%) of those aged 65 years and above who took part in the study had two or more long-term conditions, for which they could have been taking a range of medicines. Read full story Source: Community Pharmacy News, 17 February 2020 -
News Article
Up to 100,000 on antipsychotics with no review
Patient Safety Learning posted a news article in News
A national strategy is needed to tackle health risks linked to antipsychotic drugs because current policy is letting tens of thousands of people fall through the gaps, commissioners in London are warning. Commissioners and clinicians in City and Hackney found more than 1,000 patients in their area who were on these drugs without having regular medication reviews or health checks. They warned that, if their findings applied across England, 100,000 patients could be in the same position. Although NHS England funds GP practices to carry out regular health checks on patients who are on the serious mental illness register, this excludes patients who are prescribed antipsychotics without having an SMI diagnosis — which typically covers psychoses, schizophrenia or bipolar active disorder. An audit by City and Hackney Clinical Commissioning Group, carried out in July 2019 and shared with HSJ, found 1,200 patients in the area were taking antipsychotics but did not have a formal SMI diagnosis. The audit found most of these patients were not receiving regular health checks and a significant number may have benefited from having their medication reduced. Read full story (paywalled) Source: HSJ, 27 January 2020 -
News Article
Ways to identify EHR usability issues and reduce patient harm
Patient Safety Learning posted a news article in News
An electronic health record (EHR) bug that transmits and medication order for 25 mg of a drug – not the prescribed 2.5 mg – could be the difference between life and death. And it’s that seemingly impossible reality that’s bringing more industry stakeholders to the table working to better understand EHR usability and its effects on patient safety. “Often times when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, Director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence. “In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured. All of those things shape usability.” EHR usability issues are an exceptionally common issue, Ratwani reported in a recent JAMA article. About 40% EHRs reported having an issue that can potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting. Direct safety challenges typically come from EHR products that are sub-optimally designed, developed, or implemented. Usability issues stem from a very cluttered interface or a complex medication list. Seeing a cluttered list can lead to a clinician selecting the wrong medication. A major usability issue also comes from data entry. EHR users want that process to be as clean as possible. Consistency in the way information is entered is also key, Ratwani explained. Ratwani also wants to ensure that certification testing is as realistic as possible. He compared it to when a vehicle is certified to meet certain safety standards each year. This type of mechanism does not exist when it comes to EHRs because right when the product is certified, it then gets implemented, and there is no further certification of safety done at all after the initial testing. “One way to do that, at least for hospitals, is to have that process be something that the Joint Commission looks to do as part of their accreditation standards,” Ratwani said. “They could introduce some very basic accreditation standards that promote hospitals to do some very basic safety testing.” Read full story Source: EHR Intelligence, 13 January 2020 -
News Article
Improve brand and batch number recording, urge drug safety professionals
Patient Safety Learning posted a news article in News
New research from the UK’s Drug Safety Research Unit (DSRU) has found that hospital pharmacists, doctors and nurses only recorded batch numbers for biologic medicines between 38% and 58% of the time during routine hospital practice. Further, an analysis of spontaneous adverse drug reaction (ADR) reports showed that brand names were only included 38% of the time, while batch number traceability was only 15%. Because of the study results, the DSRU is encouraging health professionals to improve the recording in order to aid patient safety, suggesting that it has “some way to go to encourage health professionals to record this information.” Read full story Source: PharmaTimes Online, 7 January 2020 -
News ArticleMore than 80% of patients who have signs of a deadly sepsis infection before high-risk surgery are not getting antibiotics fast enough, a major NHS report has warned. Sepsis kills an estimated 44,000 people in England every year and rapid access to antibiotics within the first hour after diagnosis is vital to halt the infection. However, a review of performance across 179 NHS hospitals has found a majority of patients undergoing emergency bowel surgery are not getting medication early enough. A leak of the bowel can cause sepsis and while antibiotics will help treat the infection, surgery is essential to repair any sepsis-causing leak. The Royal College of Anaesthetists, which carried out the study for the NHS, said although the number of patients getting surgery in time had improved over the last five years, the numbers receiving antibiotics within an hour had not. Read full story Source: The Independent, 4 January 2020
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News ArticleTwo people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal. Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage. At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died. City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed. An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world." “As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.” Read full story Source: Chronicle Live, 22 December 2019
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News ArticleA hospital has been fined £45,000 after the death of a leukaemia patient who was given five times the amount of drugs she needed. Royal Bournemouth Hospital Trust ignored repeated warnings from inspectors raising concerns about the unit where the 80-year-old patient, who was taking part in a clinical trial, was given the wrong dose on two separate occasions. The trust was fined at Bournemouth Crown Court on Monday after pleading guilty in August to supplying a medicinal product that was not of the nature or quality demanded. Investigations revealed that, while staff spotted the incorrect dosage, they were wrongly told it was fine, meaning the pensioner, who was terminally ill, was given five times the prescribed amount over four days rather than a lower dose over 10 days. An investigation by the Medicines and Healthcare products Regulatory Agency (MHRA) found staff were working “beyond capacity”. Inspections in 2012, 2013, 2015 and 2017 all found the unit was running over capacity and highlighted it as an issue that urgently needed addressing to prevent any mistakes being made. Read full story Source: The Independent, 12 December 2019
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News Article
Australia: ‘Medicine safety is a priority for us all.’
Patient Safety Learning posted a news article in News
Stakeholders from across various sectors in Australia attended a medicine safety forum convened in Canberra on Monday. Held by the Consumers Health Forum of Australia (CHF), Pharmaceutical Society of Australia (PSA), the Society of Hospital Pharmacists of Australia (SHPA), NPS MedicineWise and academic partners Monash University and University of Sydney, the forum challenged participants to ‘think differently’ on the safe use of medicines in Australia. This included brainstorming on what success in improving medicine safety would look like in 10 years. “Medicine safety is a priority for us all and we each have a role to play,” PSA National President Associate Professor Chris Freeman said. “It was inspiring to see the sector work together today to proactively identify those measures we can cooperatively pursue to make a real difference and protect patients.” Read full story Source: AJP.com.au -
News Article
Online prescribing 'must get safer'
Patient Safety Learning posted a news article in News
More deaths could occur unless action is taken to keep people safe when obtaining medications from online health providers, says a UK coroner. Nigel Parsley has written to Health Secretary Matt Hancock highlighting the case of a woman who died after obtaining opiate painkillers online. Debbie Headspeath, 41, got the medication, dispensed by UK pharmacies, after website consultations. Her own GP was unaware of what she had requested from doctors on the internet. The Suffolk coroner has now written to the Department of Health asking for urgent action to be taken. The General Pharmaceutical Council – the independent regulator for pharmacies – said it was responding to the coroner's report and would continue to take necessary action to make sure medicines are always supplied safely online. Read full story Source: BBC News, 9 December 2019 -
News Article
Fewer than half of pharmacists issue warning cards for patients using valproate
Patient Safety Learning posted a news article in News
It is a requirement that patient cards detailing information on the risks are issued every time valproate is dispensed, under Medicines and Healthcare products Regulatory Agency (MHRA) guidance. Only 40% of pharmacists are meeting a patient safety requirement when dispensing valproate to women, an audit carried out by the Company Chemists’ Association (CCA) has found. The drug can cause birth defects in women who take it when pregnant. In April 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) stated that valproate must not be used by women and girls of childbearing age unless a pregnancy prevention programme (PPP) is in place. Duncan Rudkin, Chief Executive of the General Pharmaceutical Council (GPhC), said pharmacies must do more to ensure the safe dispensing of valproate. Read full story Source: The Pharmaceutical Journal -
News Article
Australia needs to “get real on medicine safety”
Patient Safety Learning posted a news article in News
Australia needs to “get real on medicine safety”, Federal Parliament heard this week. Speaking in the House of Representatives, Julian Hill (ALP, Vic) said “too many Australians are being seriously injured, sometimes with lifelong impacts or dying, because of the weakness in our pharmacovigilance system”. Mr Hill, Deputy Chair of the Parliamentary Joint Committee of Public Accounts and Audit, referred to a recent study by the Pharmaceutical Society of Australia which “estimated the extent of the problem at 250,000 annual hospital admissions as a result of medication related problems and 400,000 additional presentations to emergency departments, likely because of medicine related problems. There’s an annual cost of $1.4 billion, and yet 50 per cent of this harm is estimated to be preventable,” he said. “I have spoken before about my concerns in this area, and so have many other advocates, but the government is still not taking these issues seriously. Every day of inaction means Australians are at risk of death or serious harm from medicines when it could be avoided”. Read full story Source: AJP.com.au, 28 November 2019 -
News Article
CDC: More people dying from antibiotic resistance than previously believed
Patient Safety Learning posted a news article in News
More than 2.8 million antibiotic-resistant infections occur in the U.S. every year, and more than 35,000 people die as a result of those infections, according to a newly released Centers for Disease Control and Prevention (CDC) report. The updated Antibiotic Resistance Threats in the United States (AR Threats Report) also estimates when antibiotic-resistant bacterium Clostridium difficile (or C. diff) is included, that number exceeds 3 million infections and 48,000 deaths. The report, which used data sources such as electronic health records not previously available, shows that there were nearly twice as many annual deaths from antibiotic-resistant infections as the CDC originally reported in 2013. CDC officials called the numbers in this report "more precise, though still conservative, estimates of the human costs of antibiotic resistance. Read full story Source: FierceHealthcare, 13 November 2019 -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
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Content ArticleThis National Patient Safety Agency (NPSA) booklet presents information concerning how better design can be used to make the dispensing process safer in community pharmacies, dispensing doctor practices and hospital pharmacies. There are a number of new factors that will impact on the dispensing process, such as: electronic prescription services; auto-id and automation technologies; more responsibilities for pharmacy technicians; and enhanced pharmacy services. These factors have been incorporated into these safer design recommendations Organisations, managers and healthcare workers involved in dispensing medicines should use this booklet as a resource to help introduce new initiatives to further minimise harms from medicines.
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Content ArticleNearly half of all adults and approximately 8% of children (aged 5-17) worldwide have a chronic condition. Yet, studies have consistently shown that adherence to medication is poor; estimates range from under 80% to under 50%, with an average of 50%. There could be a considerable improvement in health outcomes (and consequently longevity), not only by developing new drugs, but by helping people adhere to existing treatment regimens that have already been researched, tested and prescribed for them. But adherence isn’t usually prioritised by governments, health providers or healthcare professionals (HCPs). Adherence isn’t measured at a national level for any disease, apart from in Sweden where hypertension is recorded. And as governments don’t prioritise adherence, health providers aren’t measured or incentivised for improving it, meaning HCPs may not have the time and resources (or reminders) to focus on it during consultations. This report from the International Longevity Centre-UK (ILC) makes a series of recommendations.
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Content ArticleAlthough serious medication errors are uncommon, their effects can be devastating for patients and their loved ones. The authors of this study in the journal Patient Safety searched the Pennsylvania Patient Safety Reporting System (PA-PSRS) for reports of serious medication errors in the emergency department from 1 January 2011 to 31 December 2020. They identified trends in the data, looking at patient sex, patient age, event harm score, event day of the week and event time of day. The authors found that: error reports more often specified that the patient was female. events were significantly more likely to happen over the weekend. most errors occurred at the prescribing stage. the most common error type was a wrong dose. They conclude that a number of patient safety strategies could reduce the risk of medication errors in the emergency department, including: stocking epinephrine autoinjectors. using clinical decision support at the ordering/prescribing stage of the process. adding an emergency medicine pharmacist to interdisciplinary emergency medicine teams.
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Content ArticleEZDrugID is a campaign to improve the distinctiveness of medication packaging set up by a group of healthcare workers. Inadequate standards around medication packaging mean that medications with very different actions are sometimes packaged in a very similar way causing "look-alike drugs”. This can lead to errors and serious harm to patients if the wrong drug is mistakenly used. The EZDrugID website contains information about their campaigns to maximise distinctiveness of different medications as well as a "lookalikes" gallery. See also: the hub's error traps gallery The medication safety area of the hub
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Content ArticleDisease-modifying antirheumatic drugs (DMARDs) are a group of medications commonly used in people with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and systemic lupus erythematosus (SLE). They work by work suppressing the body's overactive immune and/or inflammatory systems and take effect over weeks or months. This information guide gives information for patients on conventional and biologic DMARDS, including how they work, the different kinds available and their side effects.
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Content ArticleThe Community Pharmacy Patient Safety Group conducted this anonymous survey on patient safety culture in Autumn 2021 and invited pharmacy staff from across the UK to participate. The aim of the survey was to understand patient safety practice from the perspective of frontline pharmacy teams. Both the full results and an infographic of key results are available to download.
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Content ArticleIn 2016, the Centers for Disease Control and Prevention published prescribing guidelines for opioids. Though intended to encourage best practices in opioid prescribing, these guidelines fueled providers’ fears of opioids and led to many clinicians abandoning patients who relied on opioids for pain relief. In this article, Antje M. Barreveld reflects on the harms he may have caused by underprescribing these drugs, not overprescribing them.
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Content ArticleThis case report in the journal Cureus examines the use of dalfampridine, a drug used to improve walking in multiple sclerosis (MS) patients. Dalfampridine can have serious side effects including inducing seizures. Although the US Food and Drug Administration (FDA) recommends stopping the medication permanently after a single seizure episode, this recommendation is not widely known by health care professionals. The authors argue that there is a need to raise awareness of the FDA recommendation and the potential for dalfampridine to cause seizures amongst primary and secondary care doctors and patients.
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Content Article
This visual guide by the UK Health Security Agency shows photographs of different vaccines used in the UK routine immunisation schedule and their packaging. It includes information on trade names and abbreviations, diseases each vaccine protects against and the age at which it should be administered. -
Content ArticleSharon Hartles is a critical criminologist and member of the Open University’s Harm and Evidence Research Collaborative. In this article, Sharon reflects on the significant impact of the harm caused by Primodos, a widely used hormone pregnancy test prescribed to women in the UK between 1958 and 1970. Primodos is now known to cause miscarriage, stillbirth and birth defects, and this article examines the culture of denial and an absence of state and corporate pharmaceutical accountability that allowed patients to continue to be harmed over decades.
