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Showing results for tags 'Medication'.
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Content ArticleAnticoagulants are used hospital wide throughout the patient trajectory involving many healthcare providers. Given their widespread use and risk profile, they are classified as high risk. Despite the many precautions and vast experience with these drugs, errors often occur in daily practice. The aim of this study was to investigate which factors currently negatively affect patient safety in Az Sint-Lucas hospital in Belgium. The authors performed a retrospective data analysis based on incident reports and registered usage (2018–2019) as well as on pharmaceutical recommendations (3 months period in 2019) related to anticoagulants and antiaggregants. The data were obtained from the hospital information systems. A number of risk factors were identified, such as education of all healthcare professionals, communication, the IT systems used, the opening of temporary wards and transfer of patients within the hospital. It is our opinion that a multidisciplinary, centralised approach with a focus on monitoring is imperative. The use of a clinical pharmacist could play an important role.
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Pfizer: Medicine safety tips for patients
Patient Safety Learning posted an article in Medication
Medication errors can happen in clinics and hospitals, pharmacies, and at home. Patients and healthcare providers, however, can work together to help prevent these errors. See Pfizer's tips for patients. -
Content ArticleThis report looks at how the inaccurate use of the skin cleaning agent chlorhexidine in neonatal care caused severe chemical burns to a baby.
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Content ArticleThis article looks at a safety issue around the initiation of humidified oxygen treatment. It examines an incident which resulted in a patient's death when they did not receive oxygen.
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Content ArticleThis report highlights the risk of patient overdose when converting tacrolimus (a medicine used following organ transplantation) from an oral to intravenous route.
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Content ArticleIn this podcast episode, host Aaron Harmon speaks to Dr Neil Vargesson, chair in developmental biology at the University of Aberdeen, about the importance of Good Laboratory Practice (GLP) and why pre-clinical studies are key to keeping people safe. They discuss the history of Primodos, a hormone-based pregnancy test that was given to women between 1959 and 1978. It was developed before GLP and before standardised testing for teratogenesis (causing birth defects). There are data that suggests Primodos caused birth defects, but more questions remain.
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Content ArticleIn this BMJ paper, Jin-Ling Tang and Li-Ming Li argue that despite the lure of vaccines and new drugs, established public health measures will remain our best tool to control COVID-19 and future epidemics
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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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This joint letter calls on Maria Caulfield MP, Parliamentary Under Secretary of State for Patient Safety and Primary Care, to implement in full the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review on behalf of those harmed by the side effects of Primodos, Mesh and Sodium Valproate. It is signed by Marie Lyon from the Association for Children Damaged by Hormone Pregnancy Tests, Kath Sansom from Sling The Mesh and Emma Murphy and Janet Williams from In-Fact. -
Content ArticleIn North America, although pharmacists are obligated to ensure prescribed medications are appropriate, information about a patient’s reason for use is not a required component of a legal prescription. The benefits of prescribers including the reason for use on prescriptions is evident in the current literature. However, it is not standard practice to share this information with pharmacists.The aim of this study was to characterise the research on how including the reason for use on a prescription impacts pharmacists.The results suggest that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counseling, impact communication, and improve patient safety. Reasons that may prevent prescribers from adding the reason for use information are concerns about workflow and patient privacy.
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Content ArticleThe Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care. Alerts available on the CAS website include National Patient Safety Alerts (from MHRA, NHS England and NHS Improvement and the UK Health Security Agency (UKHSA)), NHS England and NHS Improvement Estates Alerts, Chief Medical Officer (CMO) Alerts, and Department of Health & Social Care Supply Disruption alerts.
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Content ArticleBenjamin Lee Stroud died on the 19 March 2021 at home. He lived alone but had a partner who saw him regularly. He had a previous medical history of recreational drugs, including steroids and cannabis; he was recently diagnosed as insulin dependent diabetic and had undergone a kidney transplant. He fell and injured his back at work, and developed a dependence on pain medication, some of which were purchased on the internet. His mental health issues increased as a result of his psychical health problems. A post mortem was undertaken and the cause of death was multiple drug toxicity.
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Content ArticleWhen was the last time your board discussed procurement and its role in your strategy for improving health outcomes? It’s been four months since Heather Tierney-Moore took over as interim chair of NHS Supply Chain and in this blog she reflects on the world of NHS procurement, where it has come from and where it might be going.
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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 ArticleThis training video illustrates guidance from the Department of Health on safe administration of intrathecal medications.
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This is the second in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Marie talks about her campaign for justice for families affected by hormone pregnancy tests, why she is passionate about reforming medicines regulation and the important role patient campaigners play in improving patient safety. -
Content ArticleThis article in Translational and Clinical Pharmacology aims to highlight the need to reconsider current medication dosing strategies in reproductive women. It uses the example of schizophrenia to illustrate how a woman's clinical symptoms can change throughout the ovulatory cycle, leading to fluctuations in medication responses. The authors found that healthcare professionals need to consider hormonal and clinical changes that occur with the menstrual cycle when prescribing treatments. They also call for further research to increase knowledge of the issues and find better treatment strategies in women whose symptoms change with cyclical changes in ovarian hormones. However, they warn that results from such studies should never override the symptoms and treatment responses experienced by individual clinical patients.
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Content ArticleIn this study, 156 participants were recruited and randomised to placebo (n=83) or ketamine (n=73), stratified by centre and diagnosis: bipolar, depressive, or other disorders. Two 40-minute intravenous infusions of ketamine (0.5 mg/kg) or placebo (saline) were administered at baseline and 24 hours, in addition to usual treatment. The primary outcome was the rate of patients in full suicidal remission at day 3, according to the scale for suicidal ideation total score ≤3. Analyses were conducted on an intention-to-treat basis. The findings indicate that ketamine is rapid, safe in the short term, and has persistent benefits for acute care in suicidal patients. Comorbid mental disorders appear to be important moderators. An analgesic effect on mental pain might explain the anti-suicidal effects of ketamine. There are also some useful and thought-provoking comments on this research, and a helpful visual aid.
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Content ArticleThis is the transcript of a Westminster Hall debate in the House of Commons on fulfilling the recommendations of the Cumberlege Report.
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Content ArticleThis blog by the Institute for Safe Medication Practices identifies ten medication safety concerns in the US from 2021 that still need to be addressed. These concerns are: Mix-ups between the paediatric and adult formulations of the Pfizer-BioNTech COVID-19 vaccines Mix-ups between the COVID-19 vaccines or boosters and the 2021-2022 influenza (flu) vaccines EPINEPHrine administered instead of the COVID-19 vaccine Preparation errors with the Pfizer-BioNTech purple cap or grey cap COVID-19 vaccines Errors and delays with hypertonic sodium chloride Errors with discontinued or paused infusions Infection transmission with shared glucometers, fingerstick devices, and insulin pens Adverse glycaemic event errors Every organisation needs a medication safety officer Increasing error reporting
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Content ArticleThis white paper documents a roundtable discussion held at the International Forum on Quality and Safety in Health Care in Europe 2021. Participants discussed how smart medication management can be improved to optimise healthcare quality and efficiency. The meeting was chaired by Yu-Chuan (Jack) Li, a researcher of artificial intelligence (AI) in medicine and medical informatics, and editor-in-chief of BMJ Health and Care Informatics.
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Content ArticleThis study in Scientific Reports aimed to understand the current situation of occupational exposure to blood-borne pathogens in a women's and children's hospital in China. The authors analysed the causes of exposure to provide a scientific basis for improving occupational exposure prevention and control measures.
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Blog - Safe medicine saves lives (14 January 2022)
Patient-Safety-Learning posted an article in Medication
In this blog, Roohil Yusuf, Global Pharmacy Advisor at Save the Children, looks at the different factors involved in providing access to life-saving medication, including planning, sourcing, use and management of medicines. She tells the story of Habibah, a three-year-old girl from Nigeria, who was able to access medication for Severe Acute Nutrition and tuberculosis at one of Save the Children's treatment centres. She also looks at the dangers of counterfeit and expired medicines, and explores how organisations can take steps to prevent poor quality, counterfeit or expired medicines being given to patients. -
Content ArticleThis scoping review in JMIR Human Factors looked at existing research into how including the reason for use on a prescription impacts pharmacists. It suggests that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counselling, impact communication and improve patient safety. Concerns about workflow and patient privacy may be factors that prevent the inclusion of use information. The review identified that more research is needed to better understand how the inclusion of use information affects pharmacists.
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Content ArticleOn Wednesday 26 January, the All-Party Parliamentary Group for First Do No Harm (APPG FDNH) held a virtual public meeting on the topic of redress schemes for those who have suffered avoidable harm linked to pelvic mesh, sodium valproate and Primodos. This meeting was an opportunity to hear from representatives of various patient groups about what victims need and what they are missing from current support mechanisms. Below is a recording of the meeting.
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