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Content ArticleTOXBASE is the poisons information database created and maintained by the National Poisons Information Service (NPIS). It should be the first port of call for healthcare professionals seeking poisons information in the UK. NHS facilities can register for free and individual advice on more serious or complex cases is available via the NPIS 24-hour telephone service.
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Content ArticleMedication is a common cause of preventable medical harm in paediatric inpatients. This study aimed to examine the sociotechnical system surrounding paediatric medicines management and to identify potential gaps in this system and how these might contribute to adverse drug events (ADEs). The authors advocate the following actions as a result of the insights gained about contributing factors to ADEs: processes to involve parents in the care of their children in hospital. development of skill-mix interventions to ensure appropriate expertise is available where it is needed. modified checking procedures to permit staff to use their skills and judgment effectively and efficiently.
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Content ArticleThe Parkinson’s Excellence Network has launched three new practical guides to support UK health professionals to deliver time critical Parkinson’s medication on time in hospital.
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Event
A practical guide to Human Factors in healthcare
Sam posted an event in Community Calendar
Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process, and safety. The conference delves into integrating human factors into healthcare systems and processes, clinical decision making, healthcare system design, quality of patient experience, medication safety, and workload, fatigue, and stress management. Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/a-practical-guide-to-human-factors-in-healthcare or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #HumanFactors -
Content ArticleReckitt has taken the precautionary step of recalling Nutramigen LGG stage 1 and stage 2 Hypoallergenic Formula powders because of the possible presence of Cronobacter sakazakii. Both products are foods used for special medical purposes for infants. The products are mainly prescribed but are also available without a prescription. Symptoms caused by Cronobacter sakazakii usually include fever and diarrhoea, and in severe cases may lead to sepsis or meningitis which include symptoms in infants including poor feeding, irritability, temperature changes, jaundice (yellow skin and whites of the eyes) and abnormal breaths and movements. Read Reckitt's recall notice
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News Article
Prescription drugs sold online without robust checks
Patient Safety Learning posted a news article in News
Patients' lives are being put at risk because it is too easy to buy prescription-only medicines from online pharmacies, a leading pharmacist says. A BBC investigation found 20 online pharmacies selling restricted drugs without checks - such as GP approval. In total, over 1,600 various prescription-only pills were bought during the investigation entering false information without challenge. Regulator the General Pharmaceutical Council says extra checks are needed when selling some drugs online. The BBC's findings highlight the "wild west" of buying medicines on the web, says Thorrun Govind, a pharmacist, health lawyer and former chair of the Royal Pharmaceutical Society. "The current guidance basically tells pharmacies to be robust, but do that in your own way, and we know that under this current system, patients have died," she says. The parents of a woman who died in 2020, after accidentally overdosing on medicines she bought online, are among those calling for stricter rules. Katie Corrigan, from St Erth in Cornwall, had developed an addiction to painkillers after experiencing neck pain. "Katie needed help, she didn't need more medication," says her mum, Christine Taylor. Her GP had stopped supplying the drug after realising she had been allowed to request new prescriptions prematurely and been prescribed too much. Instead, Katie, 38, was able to buy a painkiller and a drug used to treat anxiety from multiple online pharmacies without notifying her GP. The coroner at Katie's inquest confirmed her GP had not been contacted by any of the pharmacies to check the drug was safe for her. In his final report, he said the safety controls were inadequate. Read full story Source: BBC News, 5 January 2024 -
Content ArticleInterprofessional communication is of extraordinary importance for patient safety. To improve interprofessional communication, joint training of the different healthcare professions is required in order to achieve the goal of effective teamwork and interprofessional care. The aim of this pilot study from Heier et al. published in BMC Medical Education was to develop and evaluate a joint training concept for nursing trainees and medical students in Germany to improve medication error communication.
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Content ArticleAntimicrobial agents, such as antibiotics, are essential to treat some human and animal infectious diseases. Antimicrobial resistance (AMR) occurs when microorganisms change so that they are no longer affected by antimicrobial drugs used to treat them. There are different types of antimicrobials, which work against different types of microorganisms, such as antibacterials or antibiotics against bacteria, antivirals against viruses, and antifungals against fungi. Antimicrobials are often used incorrectly. The development of resistance is accelerated by the inappropriate use of these drugs, for example, using antibiotics (which help to treat bacteria) for viral infections like flu, or as a growth promoter in agriculture. Because of growing resistance, the world is running out of effective antibiotics to treat infectious diseases. Unless appropriate action is taken, decades of progress in health and medicine risk being undone. In May 2015, the World Health Assembly (WHA) endorsed a global action plan on AMR and urged all WHO Member States to develop national action plans (NAPs). The Seventy-third session of the WHO Regional Committee for Europe launched the new European roadmap on AMR (2023–2030) to help accelerate the implementation of national strategies on AMR. The new brief from WHO Regional Office for Europe highlights the important connections between AMR infection prevention and control.
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Content ArticleThe US Food and Drug Administration (FDA) list of drug names with recommended tall man (mixed case) letters was initiated in 2001 with the agency’s Name Differentiation Project. Tall man lettering (TML) is a technique that uses uppercase lettering to help differentiate look-alike drug names. Starting on the left side of a drug name, TML highlights the differences between similar drug names by capitalizing dissimilar letters (e.g., vinBLAStine versus vinCRIStine and CISplatin versus CARBOplatin). TML can be used along with colour or bolding to draw attention to the dissimilarities between look-alike drug names, and alert healthcare providers that the drug name can be confused with another drug name. The Institute for Safe Medication Practices (ISMP) 'Look-alike drug names with recommended tall man (mixed case) letters' contains drug name pairs or larger groupings with recommended, bolded uppercase letters to help draw attention to the dissimilarities in look-alike drug names. The list includes mostly generic-generic drug names, although a few brand-brand or brand-generic names are included. See also our Medication error traps gallery
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Content ArticleThe opioid epidemic has been declared a public health emergency in the US, with major news outlets calling operating rooms “unintended gateways.” In response to this emergency, a team from Thomas Jefferson University sought to decrease their organisation's contribution to the potential diversion pool—the opioids surgeons prescribe to patients which go unused. This article in the journal Patient Safety looks at the research and improvement work undertaken by the team, who concluded that surgical departments can develop opioid reduction toolkits aimed at reducing the potential diversion pool of opioids in communities.
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Content ArticleThis article in The Lancet looks at the need to prioritise palliative care and medications during armed conflict. The authors argue that the Israel–Hamas conflict amplifies the dire need for access to morphine and other essential palliative care medicines included on WHO's Model Lists of Essential Medicines in order to alleviate serious health-related suffering during humanitarian crises. They outline calls that the global palliative care community has made to the World Health Organization (WHO) and other aid organisations to: add adequate oral and injectable morphine and other pain-relieving medicines in humanitarian aid response packages ensure adequate essential medicine supplies for surgery and anaesthesia provide guidelines on the safe use of essential medicines and their distribution to all aid and health workers collaborate with receiving authorities to prevent removal of controlled medicines from emergency kits include paediatric essential medicine formulations for children. They argue that opioids and other essential palliative care medicines equip health workers with the means to relieve serious health-related suffering across clinical scenarios when curative or life-saving interventions are unavailable.
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Content ArticleWhat, when, and how often you take your medications are what make up your medication routine. The routine can be confusing if you are taking two or more medications or you need to take medications at different times of the day. When possible, keeping your medication routine simple can help prevent mistakes with medications. This newsletter from SafeMedicationUse.ca shares ideas to help patients simplify and manage their medication routine.
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Content ArticleOn 11 January 2021 an investigation into the death of Susan Ann Gladstone was started. The investigation concluded at the end of the inquest on 20 November 2023. The conclusion of the inquest was Susan died as a result of a generally unknown interaction between warfarin and tramadol which caused exceptional thinning of her blood: 1a Intraparenchymal and subarachnoid haemorrhage.
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News ArticleNHS England has been told it must take action to raise awareness about the potentially fatal interaction between tramadol and warfarin, following the death of a patient. Graham Danbury, assistant coroner for Hertfordshire, issued a prevention of future deaths report on 1 December 2023, after Susan Gladstone, from Hertfordshire, died on 8 January 2021 from a bleed in the brain. An inquest, which ended on 20 November 2023, concluded that Gladstone “died as a result of a generally unknown interaction between warfarin and tramadol, which caused exceptional thinning of her blood”. Gladstone was prescribed tramadol twice for lower back pain: on 20 December 2020 and 4 January 2021. According to the report, she had been taking the anticoagulation medication warfarin for “a number of years”. The report continues: “There was nothing to warn the prescribing doctor of any possible interaction. I found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event, fatal INR to develop. “In my opinion, actions should be taken to prevent future deaths and I believe you, NHS England, have the power to take such action.” Read full story Source: Pharmaceutical Journal, 13 December 2023
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Content ArticleThe evidence presented in this report makes the undeniable case that people living with a mental health condition and taking medicines need better access to the expertise of pharmacists across the whole spectrum of care.
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Content Article
A living WHO guideline on drugs for covid-19
Patient_Safety_Learning posted an article in Guidance
This living guideline from the World Health Organization (WHO) and published by the BMJ, incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. -
News ArticleUK organisations responsible for protecting the public from advertisements of prescription-only drugs are putting patients at risk from the harms of weight loss drugs by not enforcing the law, critics have told The BMJ. The UK’s Human Medicines Regulations 2012 prohibit the advertising of prescription drugs to the general public, and companies that break the rules can be sanctioned with fines, orders to issue a corrective statement, or prosecution. Legal responsibility for regulating advertisements for medicines in the UK rests with the Medicines and Healthcare Products Regulatory Agency (MHRA) on behalf of health ministers. But there is also a system of self-regulation with a number of organisations operating their own codes of practice, including the Advertising Standards Authority. But The BMJ has found that the MHRA has not issued a single sanction for prescription drugs in the past five years. And among 16 cases where the MHRA took action by requesting changes to advertisements for weight loss drugs from June 2022 to July 2023, all were triggered by external complaints, not internal mechanisms, and none resulted in sanctions. Read full story Source: The BMJ, 13 December 2023
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Content ArticleConflicts and wars contribute substantially to the development and spread of antimicrobial resistance (AMR). War-related factors that contribute to AMR include restricted resources, high casualties, suboptimal infection prevention control, and environmental pollution from infrastructure destruction and heavy metals release from explosives. This article in The Lancet looks at the impact of the war in Gaza on AMR. It highlights that access to essential antibiotics, primarily through donations, has been a continuous challenge due to the blockade of Gaza and that Gaza's already restricted national surveillance system for AMR adds to the challenges.
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Content ArticleWith around half a million people receiving homecare medicines services at a cost that is likely to be between £3billion and £4billion each year, there are questions over what the NHS is getting for its money and how governance and accountability within the system could be improved. This article outlines an investigation by The Pharmaceutical Journal that has revealed hundreds of patient safety incidents caused by problematic homecare medicines services.
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News Article
Warning lack of line flushing leading to ‘under delivery’ of IV antibiotics
Patient Safety Learning posted a news article in News
The under delivery of intravenous antibiotics in some NHS hospitals due to lack of polices and compliance may be contributing to antimicrobial resistance (AMR), according to a parliamentary report. Findings in the report indicated that many health service organisations do not have policies in place to reduce the risk of under delivery and those that do can struggle to comply fully with them. The report’s authors warned that the residual volume of antibiotic remaining in the line of the IV administration set can result in under delivery of up to 30% of the prescribed dose. They said that, as a result, this could be leading to possible resistance within patients, owing to the accumulative effect. Nurses involved with compiling the document have called for action. Based on the findings, the report recommended that all NHS organisations implement line flushing policies by late 2024, with support from the Department for Health and Social Care. Read full story (paywalled) Source: Nursing Times, 9 December 2023 Further reading on the hub: Short-term intermittent IV antibiotics – Understanding the issue of under delivery Understanding the importance of accurate antibiotic administration through an IV administration set (drip): A patient’s guide Top picks: 10 key resources on antimicrobial resistance -
News Article
Experts call for fewer antidepressants to be prescribed in UK
Patient_Safety_Learning posted a news article in News
Open letter to government from experts and politicians says rising usage ‘is a clear example of over-medicalisation’. Medical experts and politicians have called for the amount of antidepressants being prescribed to people across the UK to be reduced in an open letter to the government. The letter coincides with the launch of the all-party parliamentary group Beyond Pills, which aims to reduce what it calls the UK healthcare system’s over-reliance on prescription medication. Read full story Source: Guardian, 5 December 2023 -
Event
Patient safety in hospices
Patient Safety Learning posted an event in Community Calendar
This conference focuses on improving safety for hospice patients. The day will highlight best practice in improving safety in hospices, highlight new developments such as the implications of the new Patient Safety Incident Response Framework (PSIRF), and the new CQC Inspection Framework, and will focus on key clinical safety areas such as falls prevention, medication safety, reduction and management of pressure ulcers, nutrition and hydration, improving the response and investigation of incidents, preparing for onsite inspections and developing a compassionate culture in hospices. Register at https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-safety-hospices or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow the conference on Twitter @HCUK_Clare #PSHospices -
Content ArticleKnowledge about adverse drug events caused by drug–drug interactions (DDI-ADEs) is limited. Authors of this study aimed to provide detailed insights about DDI-ADEs related to three frequent, high-risk potential DDIs (pDDIs) in the critical care setting: pDDIs with international normalised ratio increase (INR+) potential, pDDIs with acute kidney injury (AKI) potential, and pDDIs with QTc prolongation potential. They found that the highly preventable nature and severity of DDI-ADEs, calls for action to optimize ICU patient safety. Use of e-triggers proved to be a promising preselection strategy.
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Content ArticleThe MHRA is asking organisations to put a plan in place to implement new regulatory measures for sodium valproate, valproic acid and valproate semisodium (valproate). This follows a comprehensive review of safety data, advice from the Commission on Human Medicines and an expert group, and liaison with clinicians and organisations. This alert is for action by: Integrated Care Boards (in England), Health Boards (in Scotland), Health Boards (in Wales), and Health and Social Care Trusts (in Northern Ireland).
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News Article“Gut-wrenching,” says Lisa McManus. She is looking for words to describe how she and other thalidomide survivors feel ahead of a historic apology by Anthony Albanese for government failings in the tragedy. She is grateful for recognition of the medical disaster and relieved that a decade of advocacy has come to fruition. Around 80 of the 146 recognised survivors will witness the apology in Canberra on Wednesday in what McManus hopes will be “a step in the healing process”. But she is also frustrated that too many others have not lived to see the day. Thalidomide caused birth defects including “shortened or absent limbs, blindness, deafness or malformed internal organs”, according to the Department of Health. The drug was not tested on pregnant women before approval, and the birth defect crisis led to greater medical oversight worldwide, including the creation of Australia’s Therapeutic Goods Administration. Survivors and independent reports have criticised the government of the day for not acting sooner to remove thalidomide from shelves when problems became apparent. McManus leads Thalidomide Group Australia, having lobbied governments for a decade for an apology and better support. She’s “extremely grateful” for the apology, and says many survivors are anxious, excited and nervous – but that the apology itself can’t be the end. “I’m relieved it’s happening, I just can’t say ‘thank you’,” McManus says. “I’m very happy to think it’s here, but it won’t fix things, and I don’t want the government thinking they will deliver this and it’ll all be fine.” Read full story Source: The Guardian, 28 November 2023
