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Found 1,130 results
  1. Content Article
    Medicines cause over 1700 preventable deaths annually in England. Coroners’ Prevention of Future Death reports (PFDs) are produced in response to preventable deaths to facilitate change. The information in PFDs may help reduce medicine-related preventable deaths. Authors of this paper, published in Drug Safety, aimed to identify medicine-related deaths in coroners’ reports and to explore concerns to prevent future deaths.
  2. Content Article
    Guidance needs to be applied in a careful, caring and person-centred way to ensure that patients benefit from, and are not harmed by, healthcare. In this blog, Dr Sam Finnikin, an academic GP in Sutton Coldfield, uses the story of 86 year-old Joan to illustrate the importance of shared decision-making in ensuring patients receive the most appropriate care. Joan was prescribed multiple medications by the hospital cardiology team after being diagnosed with acute coronary syndrome and a severely impaired left ventricle, but the medications made her feel very unwell and inhibited her quality of life. Joan then reached out to her GP surgery as she wanted to stop taking them, and Dr Finnikin realised that she and her family were unaware of the the reason each medication had been prescribed and the potential benefits and side effects of each one. After a long conversation about her priorities, Joan stopped the medications that were not benefitting her symptoms and died in peace and comfort at home a few weeks later. Dr Finnikin argues that shared decision-making is not an optional extra, but must be considered a vital part of healthcare, stating that "omitting shared decision making can be just as harmful to patients as being ignorant of clinical recommendations."
  3. Gallery Image
    Fentanyl and naloxone.jpg
    Fentanyl, a synthetic opioid, and naloxone, a medication used to reverse or reduce the effects of opioids, both in very similar bottles and packaging. Shared originally on Twitter by @sassistheword
  4. Gallery Image
    Noradrenaline and tranexamic acid.jpg
    Shared with hub by Dr Abigail Clark-Morgan: Images shared of our stocked noradrenaline ampules and tranexamic acid – these have been mixed up and we are looking to stock alternative volumes of noradrenaline to reduce the likelihood of confusion. The incident also highlighted the importance of checking all the ampules drawn up, drawing up your own medications at the point of administration and effective second checking. Part of our immediate response was to label the noradrenaline ampules to make them more obviously different (the purple ampules pictured below).

    © Healthcare UK

  5. Gallery Image
    Midazolam.jpg
    Shared from Twitter: What could go wrong? Same size, same colourings … Time for distinct and standardised size/colouring of paralytic agents?
  6. Gallery Image
    Bupivacaine and sodium chloride
    Do we need a magnifying glass in every anaesthetic room? Only a matter of time until something bad happens...
  7. Gallery Image
    Sodium chloride and levobupivacaine
    Levobupivacaine is a local anaesthetic. Labelling very similar to the Sodium chloride.
  8. Gallery Image
    Glyco ampoules.jpg
    Can you read this glyco ampoule? Very small writing on the label - difficult to read, especially when in a hurry.
  9. Gallery Image
    Solutions for injections
    Three very different solutions for injection - magnesium sulfate, water, sodium chloride - so why is the labelling so similar?
  10. Gallery Image
    Clobazam.jpg
  11. Gallery Image
    Sodium Cholride and Metronidazole.jpg
  12. Gallery Image
    Which drug is which?
    Ondansetron, metoclopramide and oxytocin. Which is which? Very different drugs but very similar bottles and labels.
  13. Gallery Image
    Sodium Chloride and paracetamol solution.jpg
    These two solutions look very similar. One is paracetamol, the other Sodium Chloride. Example of packaging/labelling contributing to adverse events.
  14. Gallery Image
    Aspirin.jpg
    A patient bought wrong aspirin from pharmacy and accidentally overdosed. Easily done with such similar packaging.
  15. Gallery Image
    Rocuronium bromide and Midazolam
    Why would manufacturers make labelling for rocuronium orange? This is something you wouldn't want to muddle up.
  16. Gallery Image
    Heparinised saline and lignocaine.jpg
  17. Gallery Image
    Calcium Gluconate and Sodium Chloride solutions.jpg
  18. Gallery Image
    Medication - generic names.png
  19. Gallery Image
    TEARDEW (COMPILED).png
  20. Gallery Image
    Learning from COVID-19 medical errors.jpg
  21. Gallery Image
    Stexerol-D3.jpg
  22. News Article
    Masks worn by doctors "aggravated" a miscommunication over the dose of an anti-epileptic drug that resulted in a man's death, a coroner has warned. John Skinner died at Watford General Hospital in May 2020. A coroner has written a Prevention of Future Deaths Report (PFDR) saying he feared the same could happen at other hospitals if action was not taken. Assistant Coroner for Hertfordshire, Graham Danbury, said in the report: "As a result of failure in verbal communication between the doctors, aggravated as both were masked, a dose of 15mg/kg was heard as 50mg/kg and an overdose was administered." Mr Danbury, writing to NHS England, said: "This is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable means of communication and expression of number." A spokesperson for West Hertfordshire Hospitals NHS Trust said: "A comprehensive action plan is in place to ensure that lessons are learned from this incident." Read full story Source: 15 February 2022
  23. News Article
    The federal government on Thursday proposed new guidelines for prescribing opioid painkillers that remove its previous recommended ceilings on doses for chronic pain patients and instead encourage doctors to use their best judgment. But the overall thrust of the recommendations was that doctors should first turn to “nonopioid therapies” for both chronic and acute pain, including prescription medications like gabapentin and over-the-counter ones like ibuprofen, as well as physical therapy, massage and acupuncture. Though still in draft form, the 12 recommendations, issued by the Centers for Disease Control and Prevention (CDC), are the first comprehensive revisions of the agency’s opioid prescribing guidelines since 2016. They walk a fine line between embracing the need for doctors to prescribe opioids to alleviate some cases of severe pain while guarding against exposing patients to the well-documented perils of opioids. “We are welcoming comments from patients who are living with pain every day and from their caregivers and providers,” said Christopher Jones, a co-author of the draft and acting director of the National Center for Injury Prevention and Control, the arm of the CDC that released the new guidelines. Read full story (paywalled) Source: The New York Times, 10 February 2022
  24. News Article
    The class B drug ketamine could help to treat people suffering from severe suicidal thoughts, a study has suggested. Researchers from the University of Montpellier in France said the sedative could save lives, as it appears to alleviate dark thoughts in patients admitted to hospital for their mental health. The finding was based on a controlled trial involving 156 adults with severe suicidal ideas, which ran from April 2015 to March 2019 in seven French teaching hospitals. The participants included people with bipolar disorder and major depressive disorder. However, patients with a history of schizophrenia were excluded from the study. Although the team found the side effects of ketamine were minor and had diminished by day four, they cautioned that more research was needed to examine its benefits. “Ketamine is a drug with a potential for abuse. Longer follow-up of larger samples will be necessary to examine benefits on suicidal behaviours and long term risks,” they wrote. Commenting on the study, Riccardo De Giorgi, a PhD student at the University of Oxford, said: "These findings indicate that ketamine is rapid, safe, and effective in the short term for acute care in hospitalised suicidal patients.” Read full story Source: The Independent, 4 February 2022 Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial
  25. News Article
    Several drug companies have been fined £35 million for colluding to raise the cost of an anti-nausea drug used by cancer patients, taking the total fines stemming from a Times investigation to £400 million. The price paid by the NHS for prochlorperazine 3mg dissolvable tablets rose by 700%, from £6.49 a packet to more than £51, between December 2013 and December 2017, costing the NHS an extra £5 million a year. The Competition and Markets Authority (CMA) has ruled that several companies broke the law by fixing the market and agreeing not to produce a rival version of the drug, which is used to treat nausea and dizziness and can be prescribed to patients having chemotherapy. Andrea Coscelli, chief executive of the CMA, said: “The size of the fines reflects the seriousness of this breach. These firms conspired to stifle competition in the supply of this important medication, so that the NHS — the main buyer of the drugs — lost the opportunity for increased choice and lower prices.” He said the CMA would not “hesitate to take action like this against any businesses that collude at the expense of the NHS”. Read full story (paywalled) Source: The Times, 3 February 2022
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