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News Article
NHS investigation body launches inquiry into medication errors in children
Patient Safety Learning posted a news article in News
The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into the risks involved in prescribing, dispensing and administering medicines to children. The investigation was triggered after HSIB was notified of an incident including a child aged four years, who, after being diagnosed with a blood clot in her leg following a surgical procedure, received ten times the intended dose of anticoagulant on five separate occasions, over three days. This, HSIB said, was owing to errors that occurred during the prescription, dispensing and administration processes. The errors resulted in the child being admitted to the paediatric intensive care unit, with evidence of a bleed in her brain, where she stayed for three months until she was discharged with an ongoing care plan. HSIB said that studies showed that prescribing errors were the most frequent type of medication error in children’s inpatient settings. The investigation will look at this and other incidents to examine the role of multidisciplinary teamworking and checking in medication errors, as well as considering the risks associated with the implementation of electronic prescribing and medication administration (ePMA) systems in clinical areas using weight-based paediatric prescribing. “‘Wrong dose’ errors are a particular risk in children’s wards,” said Alice Oborne, consultant pharmacist in safe medication practice and medicines safety officer at Guy’s and St Thomas’ NHS Foundation Trust. Read full story Source: The Pharmaceutical Journal, 26 January 2021 -
News ArticleA new state of the art institute for antimicrobial research is to open at Oxford University thanks to a £100 million donation from Ineos. Ineos, one of the world’s largest manufacturing companies, and the University of Oxford are launching a new world-leading institute to combat the growing global issue of antimicrobial resistance (AMR), which currently causes an estimated 1.5 million excess deaths each year- and could cause over 10m deaths per year by 2050. Predicted to also create a global economic toll of $100 trillion by mid-century, it is arguably the greatest economic and healthcare challenge facing the world post-Covid. It is bacterial resistance, caused by overuse and misuse of antibiotics, which arguably poses the broadest threat to global populations. The world is fast running out of effective antibiotics as bacteria evolve to develop resistance to our taken-for-granted treatments. Without urgent collaborative action to prevent common microbes becoming multi-drug resistant (commonly known as ‘superbugs’), we could return to a world where taken-for-granted treatments such as chemotherapy and hip replacements could become too risky, childbirth becomes extremely dangerous, and even a basic scratch could kill. The rapid progression of antibacterial resistance is a natural process, exacerbated by significant overuse and misuse of antibiotics not only in human populations but especially in agriculture. Meanwhile, the field of new drug discovery has attracted insufficient scientific interest and funding in recent decades meaning no new antibiotics have been successfully developed since the 1980s. Alongside its drug discovery work, the IOI intends to partner with other global leaders in the field of Antimicrobial Resistance (AMR) to raise awareness and promote responsible use of antimicrobial drugs. The academic team will contribute to research on the type and extent of drug resistant microbes across the world, and critically, will seek to attract and train the brightest minds in science to tackle this ‘silent pandemic’. Read full story Source: University of Oxford, 19 January 2021
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News ArticleIn July last year, the Independent Medicines and Medical Devices Safety Review – chaired by Baroness Cumberlege— published its landmark report, First Do No Harm. It followed a two-year review of harrowing patient testimony and a large volume of other evidence concerning three medical interventions: Primodos, sodium valproate and pelvic mesh. Yesterday, in a written statement to Parliament, the Minister for Patient Safety, Suicide Prevention and Mental Health, Nadine Dorries, gave an update on the government’s response to the recommendations of the Cumberlege Review. In an article in The Times today, Baroness Cumberlege welcomes that the government has now accepted the need for a patient safety commissioner for England and the amendment to the Medicines and Medical Devices Bill, which is being considered in the House of Lords today, which she hopes "will swiftly become law". However, she also states that "... a full response to the review's is still outstanding 6 months after publication. Action is urgently needed to ensure we help those who have already suffered and reduce the risk of harm to patients in future". Read full story (paywalled) Source: The Times, 12 January 2021
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News ArticleThe first new sickle-cell treatment in 20 years will help keep thousands of people out of hospital over the next three years, NHS England has said. Sickle-cell disease is incurable and affects 15,000 people in the UK. And the National Institute for Health and Care Excellence said the hope of reducing health inequalities for black people, who are predominantly affected and often have poorer health to start with, made the drug worth recommending. It called it "an innovative treatment". Read full story Source: BBC News, 5 October 2021
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News Article
Overprescribing of medicines must stop, says government
Patient Safety Learning posted a news article in News
Many patients are being prescribed unnecessary and even harmful treatments, a new report warns. The review, in England, suggests one-tenth of items dispensed by primary care are inappropriate or could be changed. Around 15% of people take five or more medicines a day - some are to deal with the side-effects of the others. The government is appointing a prescribing tsar to help with the issue and stop waste. Overprescribing can happen when: a better alternative is available but not given the medicine is appropriate for a condition but not the individual patient a condition changes and the medicine is no longer appropriate the patient no longer needs the medicine but continues to be prescribed it. Chief pharmaceutical officer for England, Dr Keith Ridge, said: "Medicines do people a lot of good and this report is absolutely not about taking treatment or services away from people where they are effective. But medicines can also cause harm and can be wasted." Read full story Source: BBC News, 22 September 2021 -
News Article
Opioid pain relief 'soared during pandemic' for some patients
Patient Safety Learning posted a news article in News
The use of opioids for pain relief soared during the pandemic as some patients waited longer for surgery, according to new research. The University of Aberdeen team focused on more than 450 patients due to have hip or knee replacement surgery. They said waiting times for these procedures increased by an average of 90 days and that the numbers of patients using opioids while waiting for surgery increased by 40% compared to pre-pandemic levels. The research, published in the BMJ Quality and Safety, looked at data collected from 452 NHS patients from the north east of Scotland. The university's Luke Farrow, who led the research, said alternative ways of managing severe arthritis pain needed to be found "urgently" for those waiting for this kind of surgery. Read full story Source: BBC News, 15 November 2021 -
News ArticleThe deaths of three adults with learning disabilities at a failed hospital should prompt a review to prevent further "lethal outcomes" at similar facilities, a report said. The report looked at the deaths of Joanna Bailey, 36, and Nicholas Briant, 33, and Ben King, 32, between April 2018 and July 2020. It found here were significant failures in the care of the patients at Jeesal Cawston Park, Norfolk. Ms Bailey, who had a learning disability, autism, epilepsy and sleep apnoea, was found unresponsive in her bed and staff did not attempt resuscitation, while the mother of Mr King said he was "gasping and couldn't talk" when she last saw him. Mr Briant's inquest heard he died following cardiac arrest and obstruction of his airway after swallowing a piece of plastic cup. The report found: "Excessive" use of restraint and seclusion by unqualified staff. Concerns over "unsafe grouping" of patients. Overmedication of patients. High levels of inactivity and days of "abject boredom". Relatives described "indifferent and harmful hospital practices" and said their questions and "distress" were ignored Joan Maughan, who commissioned the report as chairwoman of the Norfolk Safeguarding Adults Board, said: "This is not the first tragedy of its kind and, unless things change dramatically, it will not be the last." Read full story Source: BBC News, 9 September 2021
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News Article
Alarm raised years before hospital’s ‘inadequate’ rating
Patient Safety Learning posted a news article in News
Multiple concerns were being raised about an inpatient hospital for several years before it was rated ‘inadequate’ by the Care Quality Commission (CQC), HSJ has learned. Huntercombe Hospital in Maidenhead, which provides NHS-funded mental healthcare for children, was put into special measures in February after an inspection raised serious concerns over the apparent over-use of medication to sedate patients, among other issues. It has since received a further warning notice. The unit, which predominantly treats female patients, had previously been rated “good” by the CQC in 2016 and 2019. Five former patients and four parents have now told HSJ of poor care and practices at the unit between 2016 and 2020. Two of the families raised concerns directly to Huntercombe, as well as NHS England, local authorities and the local community provider, Berkshire Healthcare FT. Read full story (paywalled) Source: HSJ, 18 May 2021 -
EventuntilUnsafe 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. Ensuring medication safety in polypharmacy is one of the critical challenges in medication safety. Inappropriate polypharmacy has been described as a significant public health challenge, as it increases the likelihood of adverse effects, considerably impacting health outcomes and expenditure on health care resources. Countries need to prioritize raising awareness of the problems associated with inappropriate polypharmacy and the need to address this issue. All stakeholders have a vital role in driving change for the management of polypharmacy. At this webinar, we will introduce the WHO technical report on “Medication Safety in Polypharmacy”, and experiences from different countries and organizations will be shared on the proper management of polypharmacy and the factors that influence appropriate polypharmacy. The session will be available in English, French and Spanish. Register for the webinar
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EventuntilCollaboration to deliver NHS Long Term Plan goals on CVD and Population Health Management A novel injectable treatment for people at risk of cardiovascular disease is being made available to patients more quickly, thanks to a three-way agreement between NHS England and NHS Improvement, the AHSN Network and the pharmaceutical company, Novartis. Inclisiran is the first of a new type of cholesterol-lowering therapy, which uses RNA interference (RNAi) to boost the liver’s ability to remove harmful cholesterol from the blood. It can be given to people with high cholesterol who have already had a previous cardiovascular event to reduce the chances of them having another. This webinar will introduce this innovative injectable therapy, explore it’s its place on the treatment pathway, and how it can support both the NHS Long Term Plan dual ambitions of reducing cardiovascular disease and through Population Health Management. Register for the webinar
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EventuntilThe International Alliance of Patients’ Organizations (IAPO) and Patient Academy for Innovation and Research (PAIR Academy) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The 4th webinar of the medication without harm webinar series is scheduled on June 18th, 2022, from 11:30 to 12:30 GMT. The theme is "Importance of Systems and Safe Medication Practices for patient safety”. This webinar will emphasize on the "Importance of Systems and Safe Medication Practices for patient safety ", within WHO’s Global Patient Safety Challenge: Medication Without Harm, to improve medication safety. The patient safety series of webinars will focus on the strategic framework of the Global Patient Safety Challenge, which depicts the four domains of the challenge: patients and the public, health care professionals, medicine, and systems and practices of medication, and the three key action areas—namely polypharmacy, high-risk situations, and transitions of care, The series of webinars will share challenges, technical strategies, tools, and patient experiences in implementing the Strategic Framework of the Global Patient Safety Challenge to reduce medication-related harm. Register for the webinar
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Event
The future for medicine regulation
Patient Safety Learning posted an event in Community Calendar
untilThis Westminster conference will examine key issues for medicine regulation, looking at next steps for clinical trials and patient involvement. Overall, key areas for discussion include: regulation - the MHRA’s Delivery Plan for 2021-23 - the evolving role and scope of the regulator - developing new approaches to regulation - partnerships. clinical trials - priorities for change following consultation - public involvement - efficiency - transparency - issues for ensuring patients are listened to and responded to as part of the process. innovation - regulatory support - developing frameworks to facilitate safe access to innovative products & new therapies - options for streamlining & fast-track approvals. wider priorities - evidence collection - improving health outcomes - engagement with the wider life sciences ecosystem - the UK’s international role. Keynote sessions with Dr Glenn Wells, Chief Partnerships Officer, MHRA; Juliet Tizzard, Director of Policy and Partnerships, Health Research Authority; Dr Ali Hansford, Head of Regulatory Strategy Policy, ABPI; and Meindert Boysen, Director, Centre of Health Technology Evaluation, NICE. The conference will be an opportunity for stakeholders to consider the issues alongside key policy officials who are due to attend from the DHSC; DIT; MHRA; GLD; OLS; and The Scottish Government. Register -
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. With each transition of care (as patients move between health providers and settings), patients are vulnerable to changes, including changes in their healthcare team, health status, and medications. Discrepancies and miscommunication are common and lead to serious medication errors, especially during hospital admission and discharge. Countries and organizations need to optimise patient safety as patients navigate the healthcare system by setting long-term leadership commitment, defining goals to improve medication safety at transition points of care, developing a strategic plan with short- and long-term objectives, and establishing structures to ensure goals are achieved. At this webinar, you will be introduced to the WHO technical report on “Medication Safety in Transitions of Care,” including the key strategies for improving medication safety during transitions of care. Register
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EventuntilPatient Academy for Innovation and Research (PAIR Academy) and the International Alliance of Patients’ Organizations (IAPO) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The 3rd webinar of the medication without harm webinar series is scheduled on 21 May 2022, from 11.30 to 12.30 GMT. The theme is "Understanding the process of Medication Management to reduce medication harm”. Register for the webinar
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EventPart of the ongoing series of monthly webinars on WHO Global Patient Safety Challenge: Medication Without Harm. Unsafe 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. In the context of medication safety, high-risk situations relate to those circumstances associated with a significant risk of medication-related harm, such as situations arising from look-alike, sound-alike (LASA) medications and high-alert medications. High-risk situations could be triggered by one or more of the following broad factors: medication, provider and patient, and systems factors (work environment). Organisations need to prospectively design and implement strategies to identify high-risk situations related to medications and build a robust system that intercepts them before they result in patient harm. At this webinar, WHO will present the WHO technical report on “Medication Safety in High-risk Situations” and experiences from different countries and organizations will be shared on how to address high-risk situations and reduce the risk of medication-related harm. Register
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EventuntilThe Medicines and Healthcare products Regulatory Agency (MHRA) will be holding a joint virtual Innovative Licencing and Access Pathway (ILAP) information and update session. This event will provide an opportunity for patient groups and patient experts to receive an update on the work of the ILAP, how the MHRA involve patient and public representatives, and future developments about how the MHRA are accelerating the time to market and facilitating patient access to innovative medicines. This event is open to all patient and public representatives who are involved in the work of any of the ILAP partners. Along with presentations from some of the ILAP team, a patient representative will share their experiences as a member of the pilot ILAP Patient and Public Reference Group. There will also be a panel discussion session with plenty of opportunity for questions from participants. 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. The theme of the second webinar of the medication without harm webinar series is "Role of Healthcare Professionals in Ensuring Medication Safety”. Register for the webinar
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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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Event
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
