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Showing results for tags 'Medication'.
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Content ArticleThe ISMP Targeted Medication Safety Best Practices for Hospitals (TMSBP) were developed to identify, inspire, and mobilise widespread, national adoption in the US of consensus-based best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications. The best practice recommendations presented in this guidance document are based on error reports received through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been reviewed by an external expert advisory panel and approved by the ISMP Board of Trustees. This initiative was first launched in 2014 and is updated with additional best practices, as needed, every two years. While targeted for the hospital-based setting, some best practices are applicable to other healthcare settings. Facilities can focus their medication safety efforts on these Best Practices, which are realistic and have been successfully adopted by numerous organisations.
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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) identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020.
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Prevention of Future Deaths report – Jamie Poole
Patient Safety Learning posted an article in Coroner reports
Jamie Lee Poole was diagnosed required the lifesaving surgery of a kidney transplant in 2011. After the transplant she was placed on a dose of immunosuppressant to prevent rejection of the transplanted kidney. One of the known side effects of the use of the medication is that it can cause low levels of magnesium within the body. Jamie was admitted to the Royal Stoke University Hospital on 27 June 2017 with low levels of magnesium and low calcium and was treated for correction of electrolyte disturbance. On the 28 June 2017 she was found on the floor having collapsed. It was discovered that she had significant swelling on her brain. This was caused by a lack of oxygen to the brain, which was either caused by a heart problem or a seizure, which on balance would have been caused by the low levels of magnesium. She was transferred to the intensive care unit at the Royal Stoke University, Stoke-on-Trent where she died. -
Content ArticlePeople with severe food allergies should carry two adrenaline autoinjector pens with them at all times, according to new guidance. Updated advice from The National Institute for Health and Care Excellence (NICE) says healthcare professionals should always offer people with severe allergies a prescription for two adrenaline auto-injectors (AAIs), which deliver potentially life-saving doses of the hormone to treat anaphylaxis, before being discharged from hospital after emergency treatment. They should also advise patients to always carry two devices with them, the guidance states.
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Content ArticleDo 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? Ireland's Health Service Executive's National Medication Safety Programme works with patients to improve the safe use of medicines.
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Content ArticleIn my tweets and posts I have suggested that patients themselves need to take more responsibility for the medicines they are prescribed. But what about vulnerable groups who may depend on decisions being made for them, and in their best interests? Whilst there are circumstances where antipsychotic (psychotropic) medicines are an appropriate option for people with autism and learning disabilities, these occasions are limited. In all cases the patient matters most, and any decision to prescribe must be part of a team based, patient-led decision, which is regularly reviewed.
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Content ArticleMore than 30 years have passed since the near-fatal medication error but Michael Villeneuve, CEO Canadian Nursing Association, recalls the moment with absolute clarity.
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Content ArticleAntipsychotic drugs are most commonly prescribed for behavioural and psychological symptoms, such as aggression or hallucinations, in people with dementia. This webpage from the Alzheimer's Society provides information on the prescription of these medications for people living with dementia, their potential side effects, and tips for carers when discussing these treatments with healthcare professionals.
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Content ArticleIn this article, Berlanda et al. discuss the safety of different medical treatments for endometriosis to relieve pain.
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Content ArticleThis survey tool from the Australian Commission on Safety and Quality in Health Care provides Australian health service organisations with a set of 14 principles supported by a variety of risk reduction strategies. The tool is intended for use in hospitals by all clinicians involved in the medication management pathway, including those with governance responsibilities within the health service. The survey tool is also intended to be applied within pharmacy and ward storage environments.
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Content ArticleIn this blog, Steve Turner, a qualified nurse, specialising in clinical educational and patient engagement, offers up four tips for managing medicines in care home settings, under the following headings: Care Homes must have a medicines policy that is regularly reviewed. People must have an accurate listing of their medicines on the day they transfer to the care home. People who live in care homes should have at least 1 multidisciplinary medication review per year. Ensure you have safe systems for administering and recording medicines. To read the full blog and to find out more about each tip, follow the link below.
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Content ArticleHow do we know how a patient is coping with their medicines once they have left our care? How do we know that they are using their medicines safely at home? Surprisingly few medicine errors in children in the home setting are reported, yet evidence suggests that parents sometimes struggle here. We can tackle this hidden medicines safety issue by putting families’ insight at the heart of our interventions. We have to ask. And not least for our infant, children and young adult patients, and their families. Medicines use in this patient group has long been known to be challenging, and many families continue to struggle to use medicines safely at home. But a collaborative approach between healthcare professionals and families can remedy this.
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Content ArticlePharmacovigilance is the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other medicine/vaccine related problem. This article, published in the journal Drug Safety, outlines how the Egypt Chapter of the International Society of Pharmacovigilance (ISoP) approached raising awareness of the importance of pharmacovigilance and reporting adverse drug reactions during MedSafetyWeek 2020.
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Content ArticleThe Defective Medicines Report Centre (DMRC) is part of the Medicines and Healthcare products Regulatory Agency (MHRA). The role of the DMRC is to minimise the hazard to patients arising from the distribution of defective medicines by providing an emergency assessment and communication system between manufacturers, distributors, wholesalers, pharmacies, regulatory authorities and users. This guide is for patients, healthcare professionals, manufacturers and distributors for reporting, investigating and recalling suspected Defective Medicinal Products.
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Content ArticleThis article describes what to be expect when coming off of antidepressants, withdrawal problems, the importance of safely tapering off medication and the need for extreme care and support for patients coming off prescribed antidepressants and benzodiazepines.
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Content ArticleThis article describes the case studies of a 65-year-old woman with a history of acute myeloid lymphoma called her oncology physician's office with symptoms of chemotherapy-induced nausea and a 66-year-old woman was prescribed estradiol vaginal tablets for post-menopausal symptoms. Cynthia Li and Katrina Marquez discuss how both patient cases resulted from human error by pharmacy staff and how although most medication errors can be directly attributed to human error, human error is often a result of poor system design and recommend 'The 8 R's' approach to reduce the risk for errors includes development of safeguards at every level of the medication use process.
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Content ArticleIn this article, published by the Harm & Evidence Research Collaborative, Sharon Hartles examines the UK Government’s response in relation to the implementation of the recommendations set out in the Independent Medicines and Medical Devices Safety Review, First Do No Harm report. She explores how the Government’s response has impacted on those harmed by the side effects of Primodos, Mesh and Sodium Valproate.
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At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. This month, our Content and Engagement Manager, Steph, has hand-picked seven resources, particularly relevant for patient safety managers working in hospital settings. Shared with us by hub members and patient safety advocates, they are jam-packed with practical tools and rich insights. -
Content ArticleThe Government has recently published it's response to the recommendations set out in the First Do No Harm report of the Independent Medicines and Medical Devices Safety Review, chaired by Julia Cumberlege. One of the recommendations was for manufacturers to publish details of payments they make to teaching hospitals, research institutions, and individual clinicians, similar to the American Physician Sunshine Payment Act. The Government has said it is “exploring options to expand and reinforce current industry schemes, including making reporting mandatory through legislation.” In this editorial, Sonia McLeod looks at the gaps that exist in the UK's current system for disclosure and highlights some important considerations when setting up a new system or process if it is to be effective. Read the full article Related reading: A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021) Independent Report of the Patient Reference Group – response to the report of the Independent Medicines and Medical Devices Safety Review (21 July 2021) No such thing as a free lunch – why recording conflicts of interests must be mandatory
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MHRA: Interactive Drug Analysis Profile
PatientSafetyLearning Team posted an article in Mediation
Interactive Drug Analysis Profiles (IDAPs) contain complete listings of all suspected adverse drug reactions or side effects that have been reported to the MHRA via the Yellow Card Scheme for a particular drug substance. This includes all reports received from healthcare professionals, members of the public, and pharmaceutical companies.This Interactive Drug Analysis Profile (iDAP) displays an overview of all UK spontaneous suspected Adverse Drug Reactions (ADRs) reported through the Yellow Card Scheme. It is important to note that reported adverse reactions have not been proven to be related to the drug, and should not be interpreted as a list of known side effects.- Posted
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Content ArticleThis report considers the role and functions that clinical commissioning group medicines optimisation teams deliver in the existing healthcare structure to improve patient care. Medicines optimisation can be defined as a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines.
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Content ArticleStopping antidepressants commonly causes withdrawal symptoms, which can be severe and long-lasting. This paper, published in Therapeutic Advances in Psychopharmacology, outlines the themes emerging from 158 respondents to an open invitation to describe the experience of prescribed psychotropic medication withdrawal for petitions sent to British parliaments.
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Flyer for WHO medsafe app
Becky T posted an article in Medication including labelling
This flyer promotes the WHO medsafe mobile app, powered by the World Health Organization (WHO). It highlights the 5 Moments for Medication Safety as is part of the 'Medication without harm' global patient safety challenge. -
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This week the Department of Health and Social Care released the UK Government’s response to the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. In this blog Patient Safety Learning sets out its reflections on this. -
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5 Moments for Medication Safety poster
Becky T posted an article in Medication including labelling
This poster, published by the World Health Organization (WHO) in 2017, summarises in a visual way the '5 Moments for Medication Safety', which are the key moments where action by the patient or caregiver can greatly reduce the risk of harm associated with the use of their medication/s. It is part of the 'Medication without harm' global patient safety challenge.
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