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Content Article
The Salford Medication Safety Dashboard (SMASH)
Claire Cox posted an article in Medication administration
The Salford Medication Safety Dashboard (SMASH) was successfully used in general practices with the help of on-site pharmacists. SMASH is a web application that flags up a list of patients who are potentially at risk from medicines they have been prescribed.- Posted
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News Article
Report finds ‘profound failings’ in Scottish NHS IT systems
Patient Safety Learning posted a news article in News
A Scottish Government committee has found that the “profound failings” of IT systems are the biggest problem facing a medicine-prescribing service that does not sufficiently focus on patients. A report from the members of Scottish Parliament on the Health and Sport Committee describes a medicines system “burdened by market forces, public sector administrative bureaucracy and under resourcing, inconsistent leadership and a lack of comprehensive, strategic thinking and imagination, allied to an almost complete absence of useable data”. The committee particularly criticised the failure of the NHS to introduce appropriate IT systems. “We are extremely disappointed that once again all roads lead to the dismal failure of the NHS in Scotland to implement comprehensive IT systems which maximise the use of patient data to provide a better service,” the report says. Committee members are calling for an overhaul of the system to allow for collection and analysis of data that would ensure the best possible outcomes for patients and cost savings for the NHS. MSPs found a “lack of care” to understand patients’ experience of taking medicines and a lack of follow up to ensure that medicines were effective or even being used. Prescribers were “instinctively reaching for the prescription pad” and not taking the time to discuss medicines with patients, nor were the principals of realistic medicine, in which patients and clinicians share decision making about their care, being followed. Read full story Source: Public Technology.net, 1 July 2020 -
News Article
Police investigating death of teenager at acute hospital
Patient Safety Learning posted a news article in News
Police in Bristol have launched investigations into the circumstances that led to the death of a teenager with autism and learning disabilities. Avon and Somerset Police told HSJ they are investigating the circumstances behind the death of Oliver McGowan in 2016, at North Bristol Trust. They said: “As part of the enquiry [officers] will interview a number of individuals as they seek to establish the circumstances around Oliver’s death before seeking advice from the Crown Prosecution Service.” Oliver died in 2016 at Bristol’s Southmead Hospital after being admitted following a seizure. He had mild autism, epilepsy and learning difficulties. During previous hospital spells he experienced very bad reactions to antipsychotic medications, prompting warnings in his medical records that he had an intolerance to these drugs. Despite this Oliver was given anti-psychotic medication by doctors at Southmead against his own and his parents’ wishes. This led him to suffer a severe brain swelling which led to his death. His death has since prompted a national training programme for NHS staff on the care of people with autism and learning disabilities. Read full story (paywalled) Source: HSJ, 1 July 2020- Posted
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Transfers of Care Around Medicines (TCAM)
Claire Cox posted an article in Medication including labelling
When some patients leave hospital they can need extra support taking their prescribed medicines. This may be because their medicines have changed or they need a bit of help taking their medicines safely and effectively. The transfer of care process is associated with an increased risk of adverse effects. 30-70% of patients experience unintentional changes to their treatment or an error is made because of a miscommunication.- Posted
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e-PAIN: e-Learning on pain management
Claire Cox posted an article in Training & education
e-PAIN is the place to start for anyone working in the NHS who wishes to better understand and manage pain. e-PAIN is a multidisciplinary programme based on the International Association for the Study of Pain's recommended multidisciplinary curriculum for healthcare professionals learning about pain management. Registration to the programme is free to all NHS staff members, those with OpenAthens accounts and students.- Posted
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Content ArticleThis info-graphic by the Faculty of Pain Medicine is a safety checklist for Interventional Pain Procedures under local anaesthesia or sedation. This has been adapted from the World Health Organization surgical checklist.
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Content ArticleGood practice in prescribing opioid medicines for pain should reflect fundamental principles in prescribing generally. The decision to prescribe is underpinned by applying best professional practice; understanding the condition, the patient and their context and understanding the clinical use of the drug. Initiating, tapering or stopping opioid medicines should be managed in agreement with the patient and all members of their healthcare team.
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Medication safety: go beyond the basics
Claire Cox posted an article in Medication including labelling
For any nurse working in a direct care setting, preparing medications and administering them to patients is part of the daily routine. Mistakes can happen at any point in the process. Administration errors are one of the most serious and most common mistakes made by nurses. The result may lengthen a hospital stay, increase costs, or have life and death implications for the patient. So, what can you do to safely administer medications? This blog gives some tips on good practice.- Posted
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Content ArticleSafe and effective pharmacological management of acute and procedural pain in neonates, infants and early childhood requires understanding of age-related changes in both the pharmacokinetic and pharmacodynamic profile of analgesics. Evidence based clinical practice guidelines incorporate both pharmacological and non-pharmacological techniques that can have complementary roles in acute pain management. The knowledge, skills, and attitudes of paediatric pain physicians must be appropriate to the developmental stage and clinical state of the patient and also encompass the role of parents and/or carers.
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ISoP: Using medicines safely during the COVID-19 pandemic
Patient Safety Learning posted an article in Guidance
The International Society of Pharmacovigilance share their first infographic for patients and carers on using medicines safely during the COVID-19 pandemic. They developed the tool because of the difficulties experienced with obtaining and using medicines safely during the COVID-19 pandemic.- Posted
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News ArticleLow dose dexamethasone reduces deaths in patients hospitalised with COVID-19 who need ventilation, according to preliminary results from the RECOVERY trial. The drug was also found to reduce deaths by one-fifth in other hospitalised patients receiving oxygen only, but no benefit was seen among COVID-19 patients who did not need respiratory support. The chief investigators from the University of Oxford trial said that the findings represent a “major breakthrough” which is “globally applicable” as the drug is cheap and readily available. Peter Horby, Professor of Emerging Infectious Diseases at the University of Oxford and a chief investigator on the trial, added, “This is the only drug that has so far been shown to reduce mortality, and it reduces it significantly. It is a major breakthrough.” Read full story Source: BMJ, 16 June 2020
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Content ArticleInadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and healthcare expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review from Conn et al. determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, the authors tested whether effects vary depending on intervention, sample, and design characteristics. Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence.
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Content Article
CPSI: Keeping seniors safe (15 May 2020)
Patient Safety Learning posted an article in Older people
The goal of this virtual discussion is to explore practical solutions for keeping seniors safe. The ideas are drawn from real life experiences noting how COVID-19 impacted seniors, their loved ones as well as healthcare workers and leaders. The focus of the discussion is on identifying safety risks together with practical solutions for seniors who live at home, in residences and long-term care facilities. Watch the webinar on demand and download the slides.- Posted
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Content ArticlePharmacy Times® interviewed Allison Hanson, PharmD, BCPS, 2019-2020 Institute for Safe Medication Practices (ISMP) International Medication Safety Management Fellow, to discuss medication safety during the coronavirus disease 2019 (COVID-19) pandemic, including key medication safety takeaways from the pandemic and current advancement efforts in the promotion of knowledge around medication safety.
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Content ArticleNorth Tees and Hartlepool NHS Foundation Trust has achieved more than double its medicines savings target, delivering the best value for the North Tees and Hartlepool region and the wider NHS. The Trust’s Pharmacy and Medicines Optimisation team together in collaboration with the multidisciplinary medical and nursing teams, finance department and commissioners developed several work streams for medicines efficiencies and quality improvement initiatives. Getting best value for medicines is one of the core business priorities for the Pharmacy & Medicines Optimisation team, through significant collaboration with the multidisciplinary teams of senior medical, nursing, finance, and wider commissioning teams. The project has significantly benefited the organisation and the wider system, through exceeding the expectation of efficiency target, it has contributed directly to improving the quality of patient care and experience as well as ensuring the financial sustainability of the organisation.
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News Article
Coronavirus: NHS to offer drug that can shorten recovery time by four days
Patient Safety Learning posted a news article in News
Selected NHS coronavirus patients will soon be able to access an experimental treatment to speed up their recovery, with the health secretary Matt Hancock suggesting it is probably “the biggest step forward’’ in medication since the beginning of the COVID-19 crisis. The anti-viral drug remdesivir will be made available to patients meeting certain clinical criteria to support their recovery in hospital. The drug is currently undergoing clinical trials around the world, including in the UK, and peer-reviewed data showed it can shorten the time to recovery by about four days. Treatment will initially be prioritised for patients who have the greatest likelihood of deriving the most benefit, according to the Department of Health and Social Care (DHSC). Satisfied the drug can help boost recovery, the government’s Medicines and Healthcare products Regulatory Agency (MHRA) approved the use of remdesivir through its early access to medicines scheme. The experimental anti-viral drug was granted emergency authorisation to treat Covid-19 in the US by the Food and Drug Administration earlier this month. Read full story Source: The Independent, 26 May 2020 -
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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News Article
Fault warning for Emerade 500 adrenaline pens
Patient Safety Learning posted a news article in News
People carrying Emerade 500 microgram adrenaline auto-injector pens should return them and get hold of a prescription for a different brand. A fault has been detected in the pens, meaning the dose of adrenaline may not be delivered when needed for people with severe allergies. The official advice comes from the Medicines and Healthcare products Regulatory Agency (MHRA). Alternative brands - EpiPen and Jext - are available up to 300 micrograms. "Action has been taken to protect patients, following detection of a fault in one component of the Emerade adrenaline auto-injector pens," an MHRA spokesperson said. "Patients should return all Emerade 500 microgram pens to their local pharmacy once they have a new prescription and have been supplied with pens of an alternative brand." If an Emerade pen does need to be used before a patient can get hold an alternative pen, the advice is that it should be pressed very firmly against the thigh. If this does not work, the patient should immediately use their second pen. Read full story Source: BBC News, 19 May 2020- Posted
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Content ArticlePharmaswiss Česka republika s.r.o. (an affiliate of Bausch & Lomb UK Limited) is recalling all unexpired batches of Emerade 500 microgram auto-injectors (also referred to as pens) from patients due to an error in one component of the auto-injector believed to cause some pens to fail to activate and deliver adrenaline.
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Content Article
CPSI: Five questions to ask about your medications
Patient Safety Learning posted an article in Medication
For patients who require multiple medications or who are transitioning between treatments, safety can become a concern. You or your loved one may be at risk of fragmented care, adverse drug reactions, and medication errors. To be an active partner in your health, you need the right information to use your medications safely. The Canadian Patient Safety Institute (CPSI) has teamed up with the Institute for Safe Medication Practices Canada, Patients for Patient Safety Canada, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists to create a list of top questions to help patients and their caregivers have a conversation about medications with their healthcare provider.- Posted
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Content ArticleThis website allows patients and professionals to report suspected side effects to medicines or medical device and diagnostic adverse incidents used in coronavirus treatment to the Medicines and Healthcare products Regulatory Agency (MRHA) to ensure safe and effective use. When reporting patients and healthcare professionals are encouraged to provide as much information as possible.
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Coronavirus (COVID-19): reuse of medicines in a care home or hospice
Claire Cox posted an article in Guidance
Standard operating procedure on how to run a safe and effective medicines reuse scheme in a care home or hospice during the coronavirus outbreak. -
News ArticleThe government is under pressure to go further on measures to relax rules on powerful painkillers such as morphine to prevent patients suffering “unnecessary pain and distress in the last days of their lives”. On Tuesday the health secretary, Matt Hancock, announced staff in care homes and hospices would be allowed to “re-use” controlled drugs such as morphine and midazolam, with medication prescribed for one patient used for another where there is an immediate need. But the Home Office today confirmed to The Independent that it had no plans to extend the rules to the care of patients in their own homes – a restriction experts and charities have warned could leave people suffering at the end of their lives. The government announced the changes following concerns over the supply of drugs. The Royal College of GPs (RCGP) welcomed the changes announced by Mr Hancock, calling them “a significant step forward”, but added: “This only applies to patients living in care home and hospice settings, so there is still work to be done to ensure patients living in their own homes have appropriate access to necessary medication in a timely way.” Last week the RCGP wrote to home secretary Priti Patel warning that people were suffering unnecessarily due to problems accessing drugs. Read full story Source: The Independent, 30 April 2020
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