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Found 1,130 results
  1. Content Article
    This 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.
  2. Content Article
    Prescription drug errors are a leading source of harm in health care, resulting in substantial morbidity, mortality and healthcare costs estimated at more than $20 billion annually in the US. Currently, clinical decision support (CDS) alerting tools – computerised alerts and reminders – are widely used to identify and reduce medication errors. However, CDS systems have a variety of limitations, including that they are rule based and can identify only medication errors that have been previously identified and programmed into the alerting logic. A new study from Rozenblum et al., published in The Joint Commission Journal on Quality and Patient Safety, used retrospective data to evaluate the ability of a machine learning system – a platform that applies and automates advanced machine learning algorithms – to identify and prevent medication prescribing errors not previously identified by and programmed into the existing CDS system.
  3. News Article
    Two people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal. Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage. At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died. City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed. An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world." “As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.” Read full story Source: Chronicle Live, 22 December 2019
  4. Content Article
    A recent report from the Healthcare Safety Investigations Branch, Investigation into electronic prescribing and medicines administration systems and safe discharge, highlighted the fact that poorly implemented ePMA (electronic prescribing and medicines administration) systems can result in potentially fatal medication errors. The report focused on the death of 75 year-old Mrs Ann Midson, following a medication error.  In this podcast interview, Pharmacy in Practice speaks to Scott Hislop and Helen Jones, two of the investigators, to discuss the series of events that ultimately culminated in the sad passing of Mrs Ann Midson.
  5. Content Article
    The Healthcare Safety Investigation Branch (HSIB) recently published a report that highlighted the fact that poorly implemented ePMA (electronic prescribing and medicines administration) systems can result in potentially fatal medication errors. The report comes after HSIB looked at the case of 75-year old Ann Midson, who was left taking two powerful blood-thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer. PRAC+TICE caught up with Scott Hislop and Helen Jones, two of the investigators, on this podcast to discuss the series of events that ultimately culminated in the sad passing of Mrs Ann Midson.
  6. Content Article
    Since the emergence of the opioid epidemic in the United States at the beginning of the 21st century, more than 400,000 Americans have died as the result of an opioid overdose. As of 2018, the Substance Abuse and Mental Health Services Administration estimates that more two million people have an opioid use disorder. With the rate of opioid-related inpatient stays and the number of opioid-related emergency department visits continuing to rise dramatically in the US, hospitals have the opportunity to make a major impact in reducing morbidity and mortality related to opioid use. This document, produced by the Institute for Healthcare Improvement, provides system-level strategies that hospitals can implement immediately to address the challenges of preventing, identifying, and treating opioid use disorder.
  7. News Article
    A hospital has been fined £45,000 after the death of a leukaemia patient who was given five times the amount of drugs she needed. Royal Bournemouth Hospital Trust ignored repeated warnings from inspectors raising concerns about the unit where the 80-year-old patient, who was taking part in a clinical trial, was given the wrong dose on two separate occasions. The trust was fined at Bournemouth Crown Court on Monday after pleading guilty in August to supplying a medicinal product that was not of the nature or quality demanded. Investigations revealed that, while staff spotted the incorrect dosage, they were wrongly told it was fine, meaning the pensioner, who was terminally ill, was given five times the prescribed amount over four days rather than a lower dose over 10 days. An investigation by the Medicines and Healthcare products Regulatory Agency (MHRA) found staff were working “beyond capacity”. Inspections in 2012, 2013, 2015 and 2017 all found the unit was running over capacity and highlighted it as an issue that urgently needed addressing to prevent any mistakes being made. Read full story Source: The Independent, 12 December 2019
  8. News Article
    Stakeholders from across various sectors in Australia attended a medicine safety forum convened in Canberra on Monday. Held by the Consumers Health Forum of Australia (CHF), Pharmaceutical Society of Australia (PSA), the Society of Hospital Pharmacists of Australia (SHPA), NPS MedicineWise and academic partners Monash University and University of Sydney, the forum challenged participants to ‘think differently’ on the safe use of medicines in Australia. This included brainstorming on what success in improving medicine safety would look like in 10 years. “Medicine safety is a priority for us all and we each have a role to play,” PSA National President Associate Professor Chris Freeman said. “It was inspiring to see the sector work together today to proactively identify those measures we can cooperatively pursue to make a real difference and protect patients.” Read full story Source: AJP.com.au
  9. Content Article
    STOMP stands for: stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life. Psychotropic medicines can cause problems if people take them for too long. Or take too high a dose. Or take them for the wrong reason. This can cause side effects like: putting on weight feeling tired or ‘drugged up’ serious problems with physical health.
  10. News Article
    More deaths could occur unless action is taken to keep people safe when obtaining medications from online health providers, says a UK coroner. Nigel Parsley has written to Health Secretary Matt Hancock highlighting the case of a woman who died after obtaining opiate painkillers online. Debbie Headspeath, 41, got the medication, dispensed by UK pharmacies, after website consultations. Her own GP was unaware of what she had requested from doctors on the internet. The Suffolk coroner has now written to the Department of Health asking for urgent action to be taken. The General Pharmaceutical Council – the independent regulator for pharmacies – said it was responding to the coroner's report and would continue to take necessary action to make sure medicines are always supplied safely online. Read full story Source: BBC News, 9 December 2019
  11. Content Article
    STOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life. Psychotropic medicines affect how the brain works and include medicines for psychosis, depression, anxiety, sleep problems and epilepsy. Sometimes they are also given to people because their behaviour is seen as challenging. People with a learning disability, autism or both are more likely to be given these medicines than other people. These medicines are right for some people. They can help people stay safe and well. Sometimes there are other ways of helping people so they need less medicine or none at all.
  12. Content Article
    STOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life.
  13. Content Article
    Public Health England have estimated that on an average day in England, between 30,000 and 35,000 adults with a learning disability, autism or both are taking a prescribed antipsychotic, an antidepressant or both without appropriate clinical indications (psychosis or affective/anxiety disorder). A substantial proportion of people with a learning disability, autism or both who are prescribed psychotropic drugs for behavioural purposes can safely have their drugs reduced or withdrawn. This research showed that among adults known to their GP to have a learning disability, (excluding only those in hospital as inpatients) on any average day: 17.0% were taking prescribed antipsychotic drugs, 16.9% antidepressants, 7.1% drugs used in mania and hypomania, 4.2% anxiolytics and 2.7% hypnotics. STOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life.
  14. Content Article
    Neptune's Dr Catherine Massey, Clinical Director, and Sophie Britt, Lead Trainer, tell us about their initiative and the difference it has made to patient safety and how it felt to win a Patient Safety Learning Award. They also discuss what they plan to do next. View video
  15. Content Article
    The Partnership for Health IT Patient Safety, a national collaborative convened by ECRI Institute, has released a new report on drug allergy interactions and how clinical decision support (CDS) and health information technology (IT) can be used to improve safety. Drug allergy alerts, a feature of clinical decision support (CDS), incorporated within the electronic health record (EHR), act as a safeguard against prescribing or dispensing a medication to which a patient has a documented allergy that could cause an adverse event for a patient. Drug allergy interactions are an important patient safety concern. Inadequate communication and display of drug allergy interaction information may result in incorrect treatment, delay care, or result in additional or prolonged care for a patient. 
  16. Content Article
    Last year, 63 healthcare professionals in England were found stealing controlled drugs and/or providing care whilst working under the influence of controlled drugs. By law, designated bodies must have a Controlled Drug Accountable Officer (CDAO).  This is a case study demonstrating the role of the CDAO and safety of controlled drugs. 
  17. Content Article
    Healthcare professionals were made aware of alerts and letters issued about adrenaline auto-injectors in September and October 2019 by the Medicines & Healthcare products Regulatory Agency. This article provides a summary of recent advice issued to healthcare professionals, including information to provide to patients, to support safe use of adrenaline auto-injectors.
  18. News Article
    It is a requirement that patient cards detailing information on the risks are issued every time valproate is dispensed, under Medicines and Healthcare products Regulatory Agency (MHRA) guidance. Only 40% of pharmacists are meeting a patient safety requirement when dispensing valproate to women, an audit carried out by the Company Chemists’ Association (CCA) has found. The drug can cause birth defects in women who take it when pregnant. In April 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) stated that valproate must not be used by women and girls of childbearing age unless a pregnancy prevention programme (PPP) is in place. Duncan Rudkin, Chief Executive of the General Pharmaceutical Council (GPhC), said pharmacies must do more to ensure the safe dispensing of valproate. Read full story Source: The Pharmaceutical Journal
  19. News Article
    Australia needs to “get real on medicine safety”, Federal Parliament heard this week. Speaking in the House of Representatives, Julian Hill (ALP, Vic) said “too many Australians are being seriously injured, sometimes with lifelong impacts or dying, because of the weakness in our pharmacovigilance system”. Mr Hill, Deputy Chair of the Parliamentary Joint Committee of Public Accounts and Audit, referred to a recent study by the Pharmaceutical Society of Australia which “estimated the extent of the problem at 250,000 annual hospital admissions as a result of medication related problems and 400,000 additional presentations to emergency departments, likely because of medicine related problems. There’s an annual cost of $1.4 billion, and yet 50 per cent of this harm is estimated to be preventable,” he said. “I have spoken before about my concerns in this area, and so have many other advocates, but the government is still not taking these issues seriously. Every day of inaction means Australians are at risk of death or serious harm from medicines when it could be avoided”. Read full story Source: AJP.com.au, 28 November 2019
  20. Content Article
    A new study published in the December 2019 issue of The Joint Commission Journal on Quality and Patient Safety details a quality improvement project by researchers at Penn Medicine, Philadelphia, USA, to reduce the risk of single-patient insulin pens.  Insulin pens are widely used in hospitals because they have multiple safety advantages compared to insulin vials, including a product name and barcode and a dial mechanism for less error-prone dosing. Despite these features, accidental sharing of pens still occurs, putting patients at risk for exposure to HIV, hepatitis B virus or hepatitis C virus.
  21. Content Article
    In Calgary, each of the three acute-care adult hospitals had different anesthetic medication carts with their own type and layout of anaesthetic medications. A number of anaesthesiologists moved among the different sites, increasing the potential for medication errors. The objective of this study from Schultz et al., published in the Canadian Journal of Anesthesia, was to identify the anesthetic medications to include and to determine how they should be grouped and positioned in a standardised anesthesia medication cart drawer. Implementation of the standardised medication drawer is expected to reduce the likelihood of medication errors. Future research should include testing the clinical implications of this standardization and applying the methodology to other areas.
  22. Content Article
    In 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.
  23. Content Article
    AHRQ’s new toolkit to improve antibiotic use in acute care hospitals. Based on the experiences of more than 400 hospitals that participated in AHRQ’s Safety Program for Improving Antibiotic Use, the toolkit guides users through its signature 'Four Moments of Antibiotic Decision Making,' a step-by-step approach for doctors to achieve optimal antibiotic prescribing. 
  24. Content Article
    The Antibiotic Guardian campaign is led by Public Health England (PHE) in collaboration with the Devolved Administrations (Scotland, Wales and Northern Ireland); the Department for Environment Food and Rural Affairs (DEFRA) and professional bodies/ organisations towards the ‘One Health’ initiative. Antibiotic resistance is one of the biggest threats facing us today. Without effective antibiotics many routine treatments will become increasingly dangerous. Setting broken bones, basic operations, even chemotherapy and animal health all rely on access to antibiotics that work. To slow resistance we need to cut the unnecessary use of antibiotics. The Antibiotic Guardian invite the public, students and educators, farmers, the veterinary and medical communities and professional organisations, to become Antibiotic Guardians.
  25. News Article
    More than 2.8 million antibiotic-resistant infections occur in the U.S. every year, and more than 35,000 people die as a result of those infections, according to a newly released Centers for Disease Control and Prevention (CDC) report. The updated Antibiotic Resistance Threats in the United States (AR Threats Report) also estimates when antibiotic-resistant bacterium Clostridium difficile (or C. diff) is included, that number exceeds 3 million infections and 48,000 deaths. The report, which used data sources such as electronic health records not previously available, shows that there were nearly twice as many annual deaths from antibiotic-resistant infections as the CDC originally reported in 2013. CDC officials called the numbers in this report "more precise, though still conservative, estimates of the human costs of antibiotic resistance. Read full story Source: FierceHealthcare, 13 November 2019
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