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EventThis conference, chaired by Simon Hammond Director of Claims Management NHS Resolution will update clinicians and managers on Clinical Negligence with a particular focus on current issues and the Covid-19 pandemic and the impact on clinical negligence claims. Featuring leading legal experts, and experienced clinicians the event will provide an update on current claims the conference will discuss why patients litigate, and responding to claims including claims regarding Covid-19. There will be an extended masterclass on trends in clinical negligence claims and responding to claims followed by an extended focus on maternity claims, and also claims related to medication error. The conference will close with a case study on the advantages of bringing together complaints, claims and patients safety investigation, and practical experiences of Coronavirus complaints at claims at an NHS Trust – including understanding the standard of care on which services should be judged, and a final session on supporting clinicians when a claim is made against them. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/clinical-negligence or email nicki@hc-uk.org.uk We are delighted to offer 3 free places for hub members. Email info@pslhub.org for the discount code. Follow on Twitter @HCUK_Clare #clinicalnegligence
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EventUnsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. WHO Patient Safety Flagship has initiated a series of monthly webinars on the topic of “WHO Global Patient Safety Challenge: Medication Without Harm”,. The main objective of the webinar series is support implementation of this WHO Global Patient Safety Challenge: Medication Without Harm at the country level. Considering the huge burden of medication-related harm, Medication Safety has also been selected as the theme for World Patient Safety Day 2022. Medication errors cause patient harm and death at a very high rate. It happens not only inside the health care facilities but also anywhere patients take medication. How to capture the medication safety incidents and learn from them have been a critical issue for patient safety. A country-wide/organsation-wide reporting and learning system that captures and analyses medication errors is proven to help estimate the magnitude of harm, identify system gaps, and develop measures to prevent reoccurrences. Furthermore, a nationwide pharmacovigilance system helps capture adverse drug reactions and informs regulators, healthcare professionals, and the public about safety concerns regarding pharmaceutical products. This webinar will discuss the medication error reporting and learning, as well as the pharmacovigilance systems which are widely used globally. Register
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EventuntilPatient Academy for Innovation and Research (PAIR Academy) and the International Alliance of Patients’ Organizations (IAPO) are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. This is the first webinar of the series and will take place at 17.00 IST (11.30 GMT). The theme is "An approach towards medication safety for patients and family." Register for the webinar
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PRSB: Overprescribing standard
Patient Safety Learning posted an event in Community Calendar
untilAround 1 in 5 hospital admissions in over-65s and around 6.5% of total hospital admissions are caused by the adverse effects of medicines. Prescribing people medicines that they neither need nor want can lead to serious harm, as identified in the Government’s 2021 National overprescribing review report. This is why the PRSB has been tasked with reviewing and revising our eDischarge summary standard and supporting documentation to ensure it addresses the issue of #oveprescribing and provide useful guidance to help users address issues. To do this, we are holding an online consultation with organisations who endorsed the 2017 eDischarge standard, the individuals and representatives who participated in the standard’s development consultations, those who have since implemented the 2017 standard and frontline health and care professionals – particularly prescribers – and people. Data standards ensure that people’s medicines information is recorded in a single, digital space that is at less risk of human error than if recorded on paper. Standards also allow for this information to be recorded in a common way that is shareable and readable across different computer systems in different care settings, for care at the point of need. Read more about how standards can support medicines reconciliation and reduce overprescribing: https://theprsb.org/prsb-response-to-national-over-prescribing-review-report/ Register -
EventThis event will: Define polypharmacy and the risk factors related to it. Illustrate the importance of Medication Reconciliation process and its implementation strategies. Recognise physicians, pharmacists and nurses’ role in this process. Speaker: Dr. Thamir M Alshammari Associate Professor of Health Outcomes, Senior Researcher, Medication Safety Research Chair, KSU Register
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EventuntilThe European Alliance for Access to Safe Medicines (EAASM) invites you to join its Parliament roundtable debate entitled “Preventing Medication errors across European hospitals to protect patient safety: Launch of the White Paper on Medication Errors and Traceability” , taking place on 22 March 2022 from 11:30 to 13:30 CET, on Zoom. The EAASM has been coordinating the European Collaborative Action on Medication Errors and Traceability (ECAMET) with the overall objective to markedly reduce medication errors (MEs) at European and national levels, to protect and enhance patient safety and the quality of health care. This event will represent the occasion to officially release a comprehensive White Paper on Medication Errors and Traceability, co-written by the EAASM and the members of the ECAMET Scientific Committee, collecting the results of a pan-European survey on medication errors which acts as a catalyst to understand where improvements can be identified and acted upon, and thus stimulate innovation in the hospital setting via proven digital processes and internal dynamic behavioural changes. Register to attend Please note, this event will take place at 11.30 CET, which is 10.30 GMT
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EventThis event from the Saudi Patient Safety Center will: Define polypharmacy and the risk factors related to it. Illustrate the importance of medication reconciliation process and its implementation strategies. Recognise physicians, pharmacists and nurses’ role in this process. Register
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EventWHO Patient Safety Flagship is planning to organise a series of monthly webinars on the topic of “WHO Global Patient Safety Challenge: Medication Without Harm”, starting from 8 February 2022. The main objective of the webinar series is support implementation of the WHO Global Patient Safety Challenge: Medication Without Harm at the country level, aligned with national efforts to implement the 72nd World Health Assembly Resolution in 2019 (WHA 72.6) on ‘Global Action on patient safety’ and the Global Patient Safety Action Plan 2021-2030. It is envisaged that the webinar series will contribute to improving medication safety practices and building competent, skilled and compassionate health workforce through education and training. Specific objectives of the webinar series are: Advocate for addressing medication safety as priority and an essential component of patient safety across all levels of health care; Share experience and best practice for medication safety improvements at the point of care as well as implementation at organizational and national levels; Engage in policy dialogue around capacity building and safety culture development for medication safety and patient safety; Share best practice on how countries have addressed risks and barriers in improving medication safety; Facilitate discussions among key stakeholders on the importance of different issues and aspects related to medication safety; Share up-to-date developments across different priorities in medication safety; and Introduce tools to support implementation in the low and middle income countries. Register
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EventThis conference focuses on reducing medication errors and the level of severe, avoidable harm related to medications. The conference focuses on prioritising high risk medications and high risk patient groups to enable your interventions to have the highest impact on patient care and reduction in patient harm. The conference which aims to bring together clinicians and pharmacists, managers, and medication safety officers and leads will reflect on medication safety issues that have arisen as a result of the Covid-19 pandemic, help you to understand current national developments, and allow you to debate and discuss key issues and areas in improving and monitoring medication safety, reducing medication errors and harm in hospitals. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/reducing-medication-errors or email kate@hc-uk.org.uk hub members receive a 20% discount. Email infor@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #MedicationErrors
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EventuntilThis webinar by the Institute for Safe Medication Practices in the US is aimed at: Pharmacists, physicians, nurses Medication safety officers Quality professionals Risk managers Leaders in pharmacy and nursing Pharmacy and anaesthesia technicians Although most medications in healthcare today have a wide margin of safety, there remains some which can cause serious harm or death if they are misused. To reduce the risk of error with these “high-alert” medications, special precautions and high leverage strategies should be implemented to avoid serious patient safety events. Numerous organizations have taken steps to identify these medications, but many are still less than confident that they have taken all the necessary precautions against serious patient harm. Join the ISMP faculty as we focus particular attention on the potential safe use risks with heparin, concentrated electrolytes, and magnesium using the results from ISMP’s National Medication Safety Self Assessment® for High-Alert Medications. Faculty will review specific safety characteristics of each these important drug classes, describe self-assessment findings related to the use of these medications, and discuss the necessary practice strategies for harm prevention when using these high-alert medications. Register for the webinar 3.00pm Eastern Time (US and Canada), 8.00pm GMT
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EventuntilThis webinar by the Institute for Safe Medication Practices in the US is aimed at: Pharmacists, physicians, nurses Medication safety officers Quality professionals Risk managers Leaders in pharmacy and nursing Pharmacy and anaesthesia technicians Although most medications in healthcare today have a wide margin of safety, there remains some which can cause serious harm or death if they are misused. To reduce the risk of error with these “high-alert” medications, special precautions and high leverage strategies should be implemented to avoid serious patient safety events. Many organizations have taken steps to identify these medications, but many are still less than confident that they have taken all the necessary precautions with high-alert drugs against serious patient harm. Join the ISMP faculty as we examine and define the importance of high alert medications as part of routine patient care and review the results of ISMP’s National Medication Safety Self Assessment® for High-Alert Medications with particular attention to vasopressors and insulin. Faculty will review specific safety characteristics of each these important drug classes, describe self assessment findings related to the use of these medications and discuss the necessary strategies for harm prevention when using these medications. Register for the webinar 3.00pm Eastern Time (US and Canada), 8.00pm GMT
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EventuntilThis online event is an important update for prescribers, and for those who take prescribed medicines, on the RPS Prescribing Competency Framework. This framework was originally produced in by the National Prescribing Centre as a competency framework for all prescribers, and updated by the Royal Pharmaceutical Society (RPS) in 2016. Join this event to: Hear about the changes to the RPS competency framework for all prescribers. Hear how others in pharmacy and other healthcare professions are using the framework. Ask questions to colleagues who were involved in updating the framework. Register
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EventThe WHO Patient Safety Flagship: A Decade of Patient Safety 2020-2030 is pleased to invite you to a webinar in the Global Patient Safety Network 2021 webinar series on the third WHO Global Patient Safety Challenge: Medication Without Harm. The aim of this Global Patient Safety Network webinar series is to introduce ongoing activities of the WHO Patient Safety Flagship, with the objective of sharing knowledge and experiences on important topics on patient safety and scaling up implementation. This webinar series is open to everyone who has an interest in patient safety. Learning objectives: To understand how to reduce medication-related harm. To learn about the third WHO Global Patient Safety Challenge: Medication Without Harm and some of the technical products to support its implementation. Considerations to bear in mind when implementing the Challenge at national, subnational, facility or community level. Further information and registration
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EventThis conference focuses on reducing medication errors and resulting harm in line with the WHO Medication without Harm Programme goal to reduce the level of severe, avoidable harm related to medications by 50% over the next five years. The conference focuses on prioritising high risk medications and high risk patient groups to enable your interventions to have the highest impact on patient care and reduction in patient harm. The conference which aims to bring together clinicians and pharmacists, managers, and medication safety officers and leads will reflect on medication safety issues that have arisen as a result of the COVID-19 pandemic, understand current national developments, and to debate and discuss key issues and areas they are facing in improving and monitoring medication safety, and reducing medication errors and harm in hospitals. There will also be a focus on prescribing error following the recent HSIB investigation and the January 2021 investigation into prescribing error in children. Further information and registration or email: kerry@hc-uk.org.uk hub members receive 10% discount. Email: info@pslhub.org Follow the conversation on Twitter #MedicationErrors
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Veracuity: Innovative approaches to drug safety
Sam posted an event in Community Calendar
Veracuity was conceived out of a recognition that the practice of pharmacovigilance is performed suboptimally. That is because it relies entirely on a voluntary reporting system – one in which consumers and healthcare professionals must devote considerable energy if they were so inclined to notify somebody about a side effect they attribute to a bio-pharmaceutical product. Adverse event reporting is infrequent and cumbersome because stakeholders are only vaguely aware of their responsibility and the current system is neither easy nor fast to use. Nor does it provide reporters with any immediate helpful feedback. With only a very small percentage of adverse drug events ever reaching the attention of manufacturers or regulators, it is easy to conclude that the medical community and the public may be wholly unaware of tremendous risks and liabilities that may be attributed to drug products. This workshop allows participation in insightful conversation on the future of our industry. Program: Fishbein, J: Introduction and closing remarks. Barrett, CP: Implementation of Post-marketing Risk Management Commitment. Laugel, I: The future of pharmacovigilance with the use of artificial intelligence sounds good. Marschler, M: The use of pharmacogenomic methodologies in the pharmacovigilance evaluation of medicinal products. This webinar meets two times. Fri, Jan 29, 2021 12:00 PM - 2:00 PM GMT Fri, Jan 29, 2021 6:00 PM - 8:00 PM GMT Register 2021-workshop-flier.pdf -
Content ArticleSome patients are unable to tolerate imaging procedures such as MRIs due to pain or anxiety. In these cases, a variety of medications are routinely used prior to imaging to allow the procedure to be carried out successfully. Varying levels of sedation before imaging can be appropriate given the need for patients to remain still during the imaging process, but the minimal amount of sedation should be used to mitigate unwanted side effects and reduce the risk of adverse events. This article examines two cases that highlight the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required and when monitoring is limited or inadequate.
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Content ArticleThis is the annual report of the National Diabetes Inpatient Audit–Harms (NaDIA-Harms) programme, which aims to monitor and reduce instances of key life-threatening diabetes specific inpatient events. The programme covers hypoglycaemic rescue, diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) and diabetic foot ulcer. Overall 4,605 inpatient harms were submitted to the NaDIA-Harms audit between May 2018 and October 2020; the majority of which related to hypoglycaemic rescue (69%). This report also covers: the number of submissions of each inpatient harm. the impact of the Covid-19 pandemic on inpatient harms. patient profiles of people that experience each inpatient harm. These include demographics, diabetes characteristics, treatment targets, care processes, admission characteristics and comorbidities.
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Content ArticlePatients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. This systematic review in BMJ Quality & Safety aimed to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.
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Content ArticleStaying in hospital can be a frightening experience for people with diabetes. In 2017, an estimated 9,600 people required rescue treatment after falling into a coma following a severe hypoglycaemic attack in hospital and 2,200 people suffered from Diabetic Ketoacidosis (DKA) due to under treatment with insulin. This report by Diabetes UK outlines the patient safety issues and suggests the following measures are needed to make hospitals safer for people with diabetes: multidisciplinary diabetes inpatient teams in all hospitals better support in hospitals for people to take ownership of their diabetes better access to systems and technology more support to help hospitals learn from mistakes strong clinical leadership from diabetes inpatient teams knowledgeable healthcare professionals who understand diabetes.
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Content Article
Safe care for people with diabetes in hospital (January 2020)
Patient-Safety-Learning posted an article in Diabetes
This article in the journal Clinical Medicine looks at the safety of people with diabetes when they are admitted to hospital as an inpatient. Having diabetes in hospital is associated with increased harm. Although the National Diabetes Inpatient Audit has shown that inpatient care for people with diabetes has slowly improved over the last few years, there are still challenges in terms of providing appropriate staffing and education. Progress is still needed to ensure the safety of people with diabetes in hospital. The authors look at some of the key areas of concern for people with diabetes in hospital, including increased risk of hypoglycaemia, hyperglycaemia (including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemia state), medication errors, hospital acquired foot ulcers, increased length of stay and overall increase in death. -
Content Article
In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting. As its ‘reference case’, the investigation uses the experience of Kathleen, a 73 year old woman with type 2 diabetes who received two recognised overdoses of insulin while she was in hospital. On both occasions she became hypoglycaemic, received medical treatment, and recovered. Patient Safety Learning has published a blog reflecting on some of the key patient safety issues highlighted in this report.
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Content ArticleThe aim of this study from Avery et al. was to determine the prevalence and nature of prescribing errors in general practice; to explore the causes, and to identify defences against error. The study involved examination of 6,048 unique prescription items for 1,777 patients. Prescribing or monitoring errors were detected for 1 in 8 patients, involving around 1 in 20 of all prescription items. The vast majority of the errors were of mild to moderate severity, with 1 in 550 items being associated with a severe error. The following factors were associated with increased risk of prescribing or monitoring errors: male gender, age less than 15 years or greater than 64 years, number of unique medication items prescribed, and being prescribed preparations in the following therapeutic areas: cardiovascular, infections, malignant disease and immunosuppression, musculoskeletal, eye, ENT and skin. Prescribing or monitoring errors were not associated with the grade of GP or whether prescriptions were issued as acute or repeat items. A wide range of underlying causes of error were identified relating to the prescriber, patient, the team, the working environment, the task, the computer system and the primary/secondary care interface. Many defences against error were also identified, including strategies employed by individual prescribers and primary care teams, and making best use of health information technology.
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Content ArticleOver the past few years, concerns have been raised about the level of funding and intervention regulators have received from the pharmaceutical industry. In this article for The BMJ, investigative journalist Maryanne Demasi examines whether regulators of medical devices and medications have enough independence from the companies they are meant to regulate. She asked six of the world's biggest regulators about their funding and transparency and found that industry money permeates the world's leading regulators. This casts doubt on their ability to provide effective regulation, especially in the wake of a string of drug and device scandals.
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Content ArticleThe government has published a draft Mental Health Bill for pre-legislative scrutiny. The bill aims to modernise the Mental Health Act for the 21st century.
