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Content ArticleMedication errors are a common issue within the care home sector, impacting on the health and wellbeing of residents as well as creating challenges for care home staff and managers. This report addresses the issue of medication safety in care homes in England. Through intense engagement with a representative sample of care homes and stakeholders involving an electronic survey, workshops and conversations, Patient Safety Collaboratives have sought to understand the reasons for medication errors and how these could be avoided in the future.
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Medication safety in nursing home patients (5 July 2022)
Patient-Safety-Learning posted an article in Social care
Medication safety has long been a major issue in long-term social care due to the number of medications taken by many older people. This editorial in BMJ Quality & Safety looks at why managing medications in care homes is so complex and highlights potential interventions to improve medication safety in long-term care settings. -
Content ArticleEach year, up to 100 million people in the US experience acute or chronic pain, mainly because of short-term illnesses, injury and medical procedures. It is therefore important that patients are offered effective treatment options to reduce symptoms and improve function. Nonopioid management is the preferred option, but there are circumstances for which short-term opioid therapy is appropriate and beneficial. Finding the balance between these approaches is an ongoing problem in the management of acute noncancer pain. This cluster randomised clinical trial featured in JAMA Health Forum, aimed to assess whether clinician-targeted interventions prevent unsafe opioid prescribing in ambulatory patients with acute noncancer pain. The authors found that the use of comparison emails decreased the proportion of patients with acute pain who had never taken opioids receiving an opioid prescription. The emails also reduced the number of patients who progressed to treatment with long-term opioid therapy or were exposed to concurrent opioid and benzodiazepine therapy. They concluded that healthcare systems could add clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing.
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Content ArticleAccording to the World Health Organization (WHO), medication harm accounts for 50% of the overall preventable harm in medical care. As well as telling the story of Melissa Sheldrick, who has been campaigning to improve medication safety since her son Andrew died as a result of a medication error, this blog looks at how making it 'safe-to-say' can reduce the risk of medication errors. Healthcare systems need a culture shift that makes it safe-to-say when something has gone wrong, is going wrong, or could go wrong. The authors argue that it is only when errors are appropriately managed, reported, responded to and learned from that we can improve the system as a whole, support people impacted to heal and take informed action to prevent similar incidents from happening in the future.
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Content ArticleConfusion between drug names that look and sound alike continues to occur and causes harm in all care settings, despite persistent prevention and mitigation efforts by industry, regulators, health systems, clinicians, patients and families. This editorial in BMJ Quality & Safety examines the results of a study that assessed the effect of mixed case (often referred to as ‘tall man’) text enhancement on critical care nurses’ ability to correctly identify a specific syringe from an array of similarly labelled syringes. The authors suggest further developments in this field of research and argue that a variety of different interventions will be needed to reduce medication errors caused by drug name confusion.
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Content ArticleIn the UK, over 26% of adults take prescription medications and in the US the figure is around 66%. But up to 50% of patients fail to take their medications as prescribed. As healthcare steadily pivots towards digital health, Dr. Bertalan Meskó and Dr. Pranavsingh Dhunno ask how new technologies can improve medication management. In this article for The Medical Futurist, they look at the importance of empowering patients to reduce the risk of medication errors. They highlight five medication management technologies that could help patients improve their own medication safety: Smart pill dispensers which deliver audible and visual cues to remind patients to take medications at the right time Medication reminder apps which help manage medication regimens and can sync the data with a caregiver or doctor Digital therapeutics which support patients to make treatment decisions Digital pills which integrate tracking technology into pills themselves Telemedical platforms that allow patients to request advice or raise concerns with their doctors.
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Content ArticleIssues with medication management and errors in medication administration are major threats to patient safety. This article for the US Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network takes a look at the AHRQ's current areas of focus for medication safety. The authors look at evidence-based solutions to improve medication safety in three areas: High-risk medication use and polypharmacy in older adults Reducing opioid overprescribing, increasing naloxone access and use and other interventions for opioid medication safety Nursing-sensitive medication safety The article also explores future research directions in medication safety and highlights that these will advance patient safety overall.
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Content ArticleDespite global consensus that access to pharmaceuticals as a lifesaving commodity is a fundamental human right, 2 billion people globally still lack access to medicines. In this blog, Karrar Karrar, Access to Medicines Adviser at Save the Children, looks at why weak regulatory systems are a major patient safety issue in low- and middle-income countries. He highlights that lack of regulatory capacity results in falsified, substandard and fake medicines making their way into local pharmacies and hospitals. It also delays patient access to new medicines due to lengthy processing times. Karrar argues that governments must prioritise investments in strengthening national regulatory systems and increase cross-country collaboration to strengthen regional and global regulatory networks and systems.
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This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety. Here we list seven tools and articles related to patient engagement and medication safety, including an interview with a patient advocate campaigning for transparency in medicines regulation, a blog outlining family concerns around prescribing and consent, and a number of projects that aim to enhance patient involvement in using medications safely. -
Content ArticleBrian Edwards, Managing Director of Husoteria Ltd, shares his speaker abstract from the 5th European pharmacovigilance congress held 1-3 December 2021. To view all the speaker abstracts from the congress, published in the Therapeutics Advances in Drug Safety journal, download the attachment below.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on 5 September 2022, which calls on the Government to implement the recommendations of the Independent Medicines and Medical Devices Safety Review in full, in particular recommendation 4 of the report calling for the establishment of separate schemes to meet the costs of additional care and support to those who have suffered avoidable harm.
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Content ArticleThe Irish Health Service Executive (HSE) has produced a selection of resources and guidance to help people use medicines safely. It offers information about the Know, Check, Ask campaign, encouraging members of the public to: Know your medicines and keep a list Check that you're using the right medicine the right way Ask your health professional if you're unsure The page also includes videos about: how to use the My medicines list tool designed to ensure patients and healthcare professionals know which medications and doses the patient should be taking. 5 moments for medication safety, a campaign linked to the World Health Organizations' WHO Medsafe app.
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IHI's Open School Short: What happened to Josie?
Patient Safety Learning posted an article in Patient-centred care
In 2001, 18-month-old Josie King died of dehydration and a wrongly-administered narcotic at Johns Hopkins Hospital. How did this happen? Her mother, Sorrel King, tells the story and explains how Josie’s death spurred her to work on improving patient safety in hospitals everywhere. -
Content ArticleMedication errors are any Patient Safety Incidents (PSI) where there has been an error in the process of prescribing, preparing, dispensing, and administering, monitoring or providing advice on medicines. Medication errors can occur at many steps in patient care, from ordering the medication to the time when the patient is administered the drug. From April 1 2015 to 31 March 2020 NHS Resolution received 1,420 claims relating to errors in the medication process. Of those claims, 487 claims settled with damages paid, costing the NHS £35 million (excluding legal costs). NHS Resolution initial data for medication errors indicates that anticoagulants, opioids, antimicrobials, antidepressants, and anticonvulsants are the most common medications to be implicated in incidents.
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Content ArticleThe National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is an independent body composed of 27 national organisations. In 1995, the United States Pharmacopeial Convention (USP) spearheaded the formation of the National Coordinating Council for Medication Error Reporting and Prevention: Leading national health care organizations are meeting, collaborating, and cooperating to address the interdisciplinary causes of errors and to promote the safe use of medications.
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This year's World Patient Safety Day, due to take place on Saturday 17 September 2022, will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. In this blog for the hub, Laurence Goldberg, an independent pharmaceutical consultant, looks at how we can reduce drug administration errors by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient. -
Content Article
This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list six helpful reads related to medication safety in hospital settings. -
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Angela talks to us about how her role enables her to promote collaboration for patient safety between different layers of the healthcare system. She also tells us about how Northern Ireland is using World Patient Safety Day 2022 to help the public and healthcare staff understand how they can contribute to medication safety. -
Content ArticleThis article and video tell the story of Rihan Neupane, a baby born prematurely in Dhapasi, Nepal, who was left in a vegetative state following a series of medical errors including a missed diagnosis of meningitis. His parents had chosen a private international hospital for their maternity care, but were let down by a series of medical errors including Rihan being mistakenly given a massive paracetamol overdose. Although external hospital safety inspectors found the hospital negligent on many counts, the hospital continued to deny any wrongdoing or responsibility for Rihan's condition. Rihan's father Sanjeev Neupane talks about his family's experience in the embedded video.
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This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here -
Content ArticleThis document has been produced as part of a project to develop EU guidance for the safe management of hazardous medicinal products (HMPs) at work, including cytotoxins. The project involves the collection of information from key stakeholders across 27 European countries through direct requests, workshops and pilots. The document provides practical guidance on preventing and reducing occupational exposure to HMPs for employers, workers, occupational health and safety (OSH) services and experts, personal training managers and others concerned with advice on the safe management of HMPs at work. The project team is inviting feedback on the draft guidance by 19 September 2022. The guide primarily addresses the following problems: Lack of awareness of HMPs Lack of support tools Unclear definition of HMPs Deficiencies in the flow and/or transfer of information.
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Content ArticleIn this article, Maryanne Demasi looks at the continued prescription of Makena, an injectable synthetic hormone approved by the US Food and Drug Administration (FDA) to women who are at high-risk of premature delivery. Makena claims to reduce the risk of pre-term birth and was approved in 2011 on an accelerated pathway by the FDA following an initial trial that showed positive outcomes. However, Demasi explains, the study has been discredited as flawed in its methods and findings, and a confirmatory trial conducted by the manufacturer showed that Makena does not actually prevent preterm birth. In spite of this, and in the face of known risks, Makena is still being prescribed to pregnant women as the manufacturer has refused to withdraw it from the market. She highlights the dangers of the FDA not taking stronger action against the manufacturer of Makena, by looking at the example of Diethylstilbestrol (DES), a synthetic hormone use by women from the 1930's to the 1970s to prevent miscarriages and premature births. DES was later found to cause cancers, immune and cardiovascular disorders and other abnormalities in pregnant women, their children and their grandchildren.
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HSE Ireland - My Medicines List leaflet (January 2020)
Patient-Safety-Learning posted an article in Medication
This leaflet produced by the Irish Health Services Executive (HSE) provides a central place for patients to record information about their medications. It acts as a reference point for patients to use when discussing their medications with a healthcare professional and includes a reminder of the Know, Check, Ask campaign, aimed at reducing medication errors in the community. -
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Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. In recognition of this, in 2017 the World Health Organization (WHO) launched the Third WHO Global Patient Safety Challenge: Medication Without Harm, aimed at improving medication safety. This article provides information and resources related to the Challenge. -
Content ArticleThis recording is part of a series of webinars by the Patient Academy for Innovation and Research (PAIR Academy), The International Alliance of Patients’ Organizations (IAPO) and Dakshama Health, to introduce the Strategic Framework of the World Health Organization's Global Patient Safety Challenge - Medication Without Harm. The theme of this sixth webinar is "Medication Safety in Polypharmacy and Transitions of Care."
