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Content Article
Top medication errors reported to ISMP in 2020
Anonymous posted an article in Coronavirus (COVID-19)
One of the most important ways to prevent medication errors is to learn from errors that have occurred in professional practice and to use that information to identify potential risk points or practices to prevent similar errors. This presentation from the Institute of Safe Medicines Practices (ISMP), looks at the top medication errors reported in 2020. -
Content ArticleThe purpose of this study from Nanji et al. is to assess the rates of perioperative medication errors (MEs) and adverse drug events (ADEs) as percentages of medication administrations, to evaluate their root causes, and to formulate targeted solutions to prevent them.
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Content ArticleIt has been estimated that, on average, a serious mistake in medication administration occurs once in every 133 anaesthetic medications. Anaesthetic medications often have a narrow therapeutic window, raising the potential for adverse outcomes including harmful physiological disturbances, awareness, anaphylaxis and even death. Marshall and Chrimes in this editorial examine the causes of the medication‐handling problem and discuss solutions that address the human factors considerations.
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Content ArticleThe author of this review argues that, while many of us benefit from advances and new technologies used in medical drug development, there is one group that has barely made any gains at all: pregnant women. This review presents an overview of the current situation for this group, the issues and the available evidence; as well as exploring the barriers and options in better addressing pregnancy and maternal health. This document was written on behalf of the Birmingham Health Partners Centre for Regulatory Science and Innovation.
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Content ArticleWomen receiving treatment for epilepsy are being urged to discuss with a healthcare professional the right treatment for them if they anticipate becoming pregnant even sometime in the future, following a Medicines and Healthcare products Regulatory Agency (MHRA) safety review. Lamotrigine (Lamictal) and levetiracetam (Keppra) have been found to be safer than other antiepileptic drugs in pregnancy. The MHRA advises patients not to stop taking their current medicines without first discussing it with a healthcare professional.
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Content ArticleThis project includes the design of templates for controlled drugs, Hypnotics/Z-drugs, DMARDs (each orally administered drug has individualized template), NOACs, Warfarin, Lithium and Amiodarone. These templates prompt the user to add compulsory details before the drug can be issued for the first time or for a repeat issue. This has led to better and safer prescribing and potential to identify group of patients who either have not been reviewed or have missed essential monitoring. To avoid visual fatigue templates are short and to the point and a clinician can navigate away by one click if the required fields have been captured recently. Audits of prescribing such drugs has shown better prescribing and more patient involvement in decision making. Read more about this case study on the NICE shared learning database, via the link below.
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Content ArticleThis case study is featured on the National Institute for Health and Care Excellence (NICE) shared learning database. The associated project aims to optimise the safe use of medicines and reduce avoidable harm to patients. Objectives: To ensure prescribers in GP practices identify and report medication related incidents and near misses via the National Reporting and Learning System (NRLS) (Each practice was required to share at least 4 records with the CCG between April 2017 and March 2018) To enable CCG-wide learning opportunities and prevent further incidents in order to improve patient safety across the CCG (Themes and trends will be disseminated at least quarterly through the Prescribing newsletter). To ensure practices responded to patient safety alerts from the MHRA in a timely manner.
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Content ArticleThis article from Peden et al. reviews of some of the key topics and challenges in quality, safety, and the measurement and improvement of outcomes in anaesthesia. Topics covered include medication safety, changes in approaches to patient safety, payment reform, longer term measurement of outcomes, large-scale improvement programmes, the ageing population, and burnout. The article begins with a section on the success of the specialty of anaesthesia in improving the quality, safety, and outcomes for our patients, and ends with a look to future developments, including greater use of technology and patient engagement.
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Content ArticleThe National Institute for Health Research (NIHR)-supported RECOVERY trial has found no clinical benefit from the antibiotic azithromycin for hospitalised patients with severe COVID-19.
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Content ArticleAs prescription numbers continue to increase, it is necessary to understand the dispensing errors that can occur and how they may happen. This article is the first of two articles from Phipps et al. on dispensing errors and risk. Reducing risk and managing dispensing errors will build on the ideas proposed in this article.
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Content ArticlePharmacy teams should understand how to minimise the risk and likelihood of dispensing errors, including methods that can be used to evaluate existing processes, as well as how to deal with errors if they happen. This article from Phipps et al., in the Pharmaceutical Journal, builds upon the ideas proposed in ‘Understanding dispensing errors and risk’, and also proposes strategies and methods that should be considered for use in the pharmacy to manage the risk of dispensing errors.
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Content ArticleLaura Anne Jones MS (Member of the Senedd) tabled a formal written question concerning the implementation of the findings of the Cumberlege Review in Wales. This is the formal response from the Minister for Health and Social Services, Vaughan Gething MS.
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Content ArticleThe Medication Errors Group was established in 2017 under the leadership of Dr Brian Edwards and Professor Ian Wong.. Ensuring the safe and effective use of healthcare products is a key objective for those who work in pharmacovigilance, as well as all other stakeholders, including patients and caregivers. One key element of that is working to reduce and mitigate medication errors and other irrational use of drugs. The mission of the Medication Errors Group is To provide an opportunity for International Society of Pharmacovigilance (ISoP) members, and like-minded collaborators, to network globally in a professional and neutral environment, to share evidence and solutions that can ideally eliminate and/or at least reduce the number and severity of medication errors. This will enable continuous improvement in the use of medicines whilst supporting the interests of patients and their families, and healthcare professionals.
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Content ArticleIn 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in their intensive care unit (ICU), Leslie et al. surveyed current practice in arterial line management and determined whether these recommendations had been adopted. They contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented – use of sodium chloride 0.9% as flush fluid, two‐person checking of fluids before use – and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two‐person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. This survey provides evidence of continuing risk to patients.
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Content ArticleSusan Warby, 57, was mistakenly given a glucose rather than a saline drip at West Suffolk Hospital after an operation for a perforated bowel in July 2018. Staff noticed a rise in blood sugar concentrations but gave her insulin to lower them rather than check the drip, which remained in place for 36 hours. In 2008 the National Patient Safety Agency made recommendations for safe arterial line management. In 2014 the Association of Anaesthetists published guidelines aimed specifically at preventing such events. Structured processes to prevent inadvertent use of a glucose-containing fluid to flush an arterial line and regular blood glucose sampling from a location other than the arterial line are only partial solutions. However, a survey of management of arterial lines undertaken in 2013 indicated that this was a common problem, that many of the NPSA recommendations were not widely implemented and that almost one third of respondents were aware of ‘wrong flush’ errors on their unit and a further third in other locations within their hospital. In this Rapid Response in the BMJ, Tim Cook says now is the time for patient representatives, clinicians, regulators and industry to work together to achieve widespread implementation of an engineered solution to prevent arterial line errors.
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Content ArticleIn 2008, the National Patient Safety Agency (NPSA) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose‐containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. Gupta and Cook report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. They report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. They discuss the nature of the errors that occurred and list the consequent changes in practice implemented in their unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.
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Content Article
Breastfeeding and medication
PatientSafetyLearning Team posted an article in Women's health
This website has been developed by Wendy Jones BSc, MSc, PhD, MRPharmS, a Community Pharmacist for over 40 years. This website is designed to provide information and support for mothers and healthcare professionals struggling to balance the benefits of breastfeeding with the perceived risk of exposing the baby to medication through his/her mother’s breastmilk.The information provided is based upon Wendy's many years experience gained as a pharmacist and from running the BfN national Drugs in Breastmilk Help-line. -
Content ArticleThis was a debate from the Scottish Parliament on the 8 September 2020 concerning the recommendations in the recently published First Do No Harm report by the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege (also known as the Cumberlege Review). The debate centred on a motion put forward by Jeane Freeman MSP, Cabinet Secretary for Health and Sport, which read as follows: That the Parliament welcomes the recommendations made by Baroness Cumberlege in her report on the independent medicines and medical devices safety review; acknowledges the Scottish Government's apology to women and families affected by Primodos, sodium valproate and transvaginal mesh; welcomes the Scottish Government’s commitment to establish a Patient Safety Commissioner, and notes the actions taken by the Scottish Government to offer improved services for women who have suffered complications as a result of transvaginal mesh.
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Content ArticleThis was a debate from the House of Lords on the 2 September 2020 on the second reading of the Medicines and Medical Devices Bill 2019-21. The intention of this bill is to confer power to amend or supplement the law relating to human medicines, veterinary medicines and medical devices; make provision about the enforcement of regulations, and the protection of health and safety, in relation to medical devices; and for connected purposes.
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Content ArticlePatients often carry medication lists to mitigate information loss across healthcare settings. The authors of this paper, published in BMJ Quality & Safety, aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use.
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Content ArticleA review on the extent of medication errors and recommendations to reduce medication-related harm in England. The Short Life Working Group report makes recommendations for a programme of work to tackle medication error and improve medicine safety.
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Content ArticleThis document was drafted on the basis of the Transparency Committee opinion, French National Authority for Health, dated 27 February 2019. It found insufficient clinical benefit of ESMYA* for the treatment of uterine fibroids to justify reimbursement. They conclude: The actual clinical benefit of ESMYA is insufficient to justify its reimbursement by public funding in its two indications. Not approved for non-hospital pharmacy reimbursement or for hospital treatment. *ESMYA - (ulipristal acetate), progesterone receptor modulator.
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Content ArticleThis interview in the Journal of Quality and Patient Safety highlights the career and motivations of Dr. Gordon Schiff, a leader in patient safety whose has focused his efforts on improving medication safety, diagnostic safety and the role of information technology in enhancing care.
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Content ArticleHealthcare Quarterly is a Canadian publication and this issue, supported by the Canadian Patient Safety Institute (CPSI), focuses on patient safety.
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Content Article
Medication safety: "Know Check Ask"
Claire Cox posted an article in Resources for patients
Do you know your medicines? Do you keep a list? Can you describe and discuss your medicines with healthcare professionals and family when you want to? Keeping track of your medicines and communicating about them can be tricky as there can be so many details to remember. This is especially important if you have a healthcare appointment or are going to hospital. This "Know Check Ask" campaign website is here to help. Please click on the content below to learn more about taking medicines safely.
