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Content ArticleThis report by the Access to Medicine Foundation looks at how the pharmaceuticals industry can help tackle antimicrobial resistance (AMR) by improving access to medicines. It sets out how the unstable antibiotic market, with its fragile supply chains and tough market conditions, hinders the development of robust models that would allow medications to be more easily distributed and accessed. It features six case studies where companies and their partners are using a combination of access strategies to cut through the complexity and address access at a local level.
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Content ArticleThe delivery of safe and effective healthcare to paediatric and neonatal patients presents unique challenges to the medication-use system. The diversity of patients within this population and the consequences of ontogeny on pharmacokinetics and pharmacodynamics directly impact the safe use of medications in children and increase the risk of adverse drug events. This review from Elkeshawi et al. will explore the medication-use system for hospitalised children and neonates, discuss vulnerabilities within this system, and provide examples of advancements made to improve the paediatric medication-use system.
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Content ArticleEvery year, thousands of emergency department (ED) visits result in patients being discharged with oral antibiotic prescriptions. Published studies that assess the appropriateness of these antibiotic regimens are limited. The purpose of this study from Bauman et al. was to examine the appropriateness of antibiotic prescriptions written for patients discharged from a community hospital’s ED. A total of 76% of the prescribed antibiotics were appropriate, 16% were inappropriate, and the remaining 8% were not assessable. Duration was the most common reason for a regimen to not be optimal. The most frequently inappropriately prescribed antibiotics included cephalexin (but it is noted cephalexin was included in almost half of the antibiotic regimens in this study), clindamycin, and azithromycin. Infections that were most frequently treated inappropriately were skin and soft tissue infections, dental infections, and sinusitis.
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Content ArticleThis review, published in official journal of the International Society of Pharmacovigilance, Drug Safety, is aimed at determining the overall incidence, severity and preventability of medication-related hospital admissions in Australia. In its conclusions, the authors estimate that 250,000 hospital admissions in Australia are medication-related, with an annual cost of AUD$1.4 billion to the healthcare system, and that two-thirds of medication-related hospital admissions are potentially preventable.
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Content ArticleUnequal distribution of Covid-19 antivirals means patients are buying pills online that may not be safe when taken without medical supervision, Gabriel G Plata reports in this BMJ investigation.
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Content ArticleFollowing the publication of the Independent Medicines and Medical Devices and Safety (IMMDS) Review in July 2022, the UK Government accepted a recommendation to appoint a Patient Safety Commissioner responsible for promoting safety in the context of the use of medicines and medical devices. At the Health Plus Care conference on the 19 May 2022, Patient Safety Learning's Chief Executive Helen Hughes and Marie Lyon, Chair of the Association for Children Damaged by Hormone Pregnancy Tests, considered the key challenges that will faced by the new Patient Safety Commissioner and the importance of implementing in full the recommendations of the IMMDS Review. See attached their presentation slides.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on 18 May 2022, which calls on the Government to implement the recommendations of the Independent Medicines and Medical Devices Safety Review in full, including paying compensation to people disabled by sodium valproate.
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Content ArticleThis thesis explores different aspects of risk and safety in healthcare, adding to previous research by studying patient safety in first-contact care, primary care and the emergency department. The author investigated preventable harm and serious safety incidents in primary health care and emergency departments, and found that diagnostic error was the most common type or error. The thesis makes recommendations for safety improvements at all levels of a healthcare system.
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Content ArticleOne box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.
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Content ArticleDespite its success in other industries, process standardisation in healthcare has been slow to gain traction or to demonstrate a positive impact on the safety of care. The High 5s project is a global patient safety initiative of the World Health Organization (WHO) to facilitate the development, implementation and evaluation of Standard Operating Protocols (SOPs) within a global learning community to achieve measurable, significant and sustainable reductions in challenging patient safety problems. The project seeks to answer two questions: (i) Is it feasible to implement standardized health care processes in individual hospitals, among multiple hospitals within individual countries and across country boundaries? (ii) If so, what is the impact of standardization on the safety problems that the project is targeting? Three SOPs—correct surgery, medication reconciliation, concentrated injectable medicines—have been developed and are being implemented and evaluated in multiple hospitals in seven participating countries. Nearly 5 years into the implementation, it is clear that this is just the beginning of what can be seen as an exercise in behaviour management, asking whether healthcare workers can adapt their behaviours and environments to standardise care processes in widely varying hospital settings.
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Content ArticleThe World Health Organization Global Patient Safety Challenge, Medication Without Harm, aims to reduce serious, avoidable medication-related harm by 50% in 5 years, globally. Three areas have been identified for early priority action. This technical report addresses Medication Safety in Transitions of Care; why it is a priority, what has been done to address it to date and what needs to be done.
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Content ArticlePresentation on the of theme of prevention of medication error from Philip A Routledge and James Coulson (All Wales Therapeutics and Toxicology Centre). Presentation available as slides a written transcript.
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Content ArticleThe Queen’s Speech was debated on Tuesday 17 May 2022. Copied below is Baroness Julia Cumberlege's excerpts on fulfilling the recommendations of the Cumberlege Report for a redress scheme.
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Content ArticleThis literature review in the Journal of Patient Safety aimed to assess lessons learned on patient safety in Organization for Economic Cooperation and Development (OECD) countries, and to assess whether they can be applied to humanitarian medicine. The authors concluded that safety culture and strategies will need to be adapted to address different intervention contexts and to respond to the concerns and expectations of humanitarian staff. As there is no overarching authority for the sector, medical humanitarian organisations, have a major responsibility in the development of a general patient safety policy in all their operations.
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Content ArticleNever Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. This document details Never Events that were reported by NHS trusts in England between 1 April 2021 and 31 March 2022. Never Events are categorised by type of incident and by trust.
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Content ArticleIn this letter to Maria Caulfield MP, the All Party Parliamentary Group (APPG) First Do No Harm raises concerns that several recommendations from The Independent Medicines and Medical Devices Safety (IMMDS) Review have not so far been taken up by the government. The IMMDS Review looked at how the health system responds to reports from patients about harmful side effects from medicines and medical devices. It specifically looked at the cases of Primodos (a hormone pregnancy test), sodium valproate (an epilepsy medication) and pelvic mesh, and found that significant harm had been caused as a result of problems in the regulatory system and the reporting of side effects. It made a number of key recommendations to the government. The APPG highlights the urgent need to establish a redress scheme for those who have suffered avoidable harm related to the products in the IMMDS Review, a recommendation for which there is widespread cross-party support. They also express disappointment that the government continues to promote the litigation route for those who have suffered harm, arguing that it is an adversarial and difficult process for patients and families who have already suffered significant harm. The letter does recognise that the government has decided to appoint a Patient Safety Commissioner, as recommended by the IMMDS Review, and highlights the significance of this step.
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Content ArticleThis infographic by the Royal College of Anaesthetists shows some of the common events and risks that healthy children and young people of normal weight face when having a general anaesthetic (GA) for routine surgery. It highlights that modern anaesthetics are very safe and that most common side effects are usually not serious or long lasting. It also outlines the conversations children and their families should expect to have with their anaesthetist prior to their procedure.
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Content ArticleThis video is based on research interviews with acute medical patients and examines how staff and patients in hospital can create safe care together. It includes quotes from real-life patient experiences and highlights the importance of listening to and reassuring patients, and involving them in their care.
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Content ArticleAdverse drug reactions (known as ADRs) can occur both in the home, and within the healthcare setting, when combinations of medications produce unexpected side effects. Unfortunately this means that in the most serious cases fatalities can occur. However ADRe has helped all service users by addressing life-threatening problems, reducing pain or improving quality of life. With preventable ADRs responsible for 5-8% unplanned hospital admissions in the UK, and costing the NHS up to £2.5bn pa, it is crucial that healthcare organisations take advantage of tools which can help improve how medicines are managed. ADRe has been developed with the aid of nursing professionals to help nursing staff take a structured approach to the monitoring of medicines, identifying any ADRs service users may be experiencing, and then making changes to improve a patients' health and wellbeing.
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Content ArticleIn a UK-first report launched in the House of Commons, leading figures from charity, healthcare, industry, law and academia have outlined a collaborative vision for UK leadership to improve maternal health. The Healthy Mum, Healthy Baby, Healthy Future: The Case for UK Leadership in the Development of Safe, Effective and Accessible Medicines for Use in Pregnancy report proposes a clear roadmap to improve the lives of millions of people, not just for women while they are pregnant, but for future generations. Over the past year, a Birmingham Health Partners led Policy Commission – co-chaired by Baroness Manningham-Buller, Co-president of Chatham House and Professor Peter Brocklehurst, University of Birmingham – has heard from key stakeholders on how best to develop safe, effective and accessible medicines for use in pregnancy. Compelling evidence gathered throughout the process has informed eight critical recommendations which, if implemented by government, will successfully prevent needless deaths and find new therapeutics to treat life-threatening conditions affecting mothers and their babies.
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Content ArticleThe Reducing Restrictive Practice Collaborative (RRP) aimed to reduce restrictive practice by one third in participating wards, measuring the following practices: Restraint – to prevent, restrict or subdue movement of the body, or part of the body of another person Seclusion – confinement in a room or physical space Rapid tranquillisation – use of sedative medication by injection. This webpage contains a number of resources related to the work of the collaborative, including a resource booklet outlining learning about running successful quality improvement projects.
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Content ArticleEffective Diabetes Education Now (EDEN) has created some resources for healthcare professionals to ensure vital information about insulin safety is communicated in way that supports the reduction of insulin errors. This webpage features infographic posters and a video about insulin safety.
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In this blog Patient Safety Learning considers several key patient safety issues highlighted in a recent investigation by the Healthcare Safety Investigation Branch (HSIB) into unintentional overdose of morphine sulfate oral solution. We argue that in some areas, further action is required to prevent incidents of avoidable harm recurring. -
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ISMP Canada Safety Bulletins
Patient Safety Learning posted an article in Medication
The Canadian Institute of Safe Medication Practice's bulletins. Learn about strategies to mitigate harm and to prevent medication errors based on analyses of medication incident reports from Canadian healthcare providers, facilities, pharmacies, organisations and consumers. -
Content ArticleThe Institute for Safe Medication Practices Canada is a trusted partner in strengthening medication safety through learning, sharing, and acting to improve healthcare. A team of experts analyse reports of medication errors from across the country and provide resources, education, and consulting services to improve medication safety.
