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Found 1,104 results
  1. Content Article
    Despite widespread efforts to combat the opioid epidemic, post-operative opioid overprescribing by doctors remains an ongoing contributor to opioid misuse. This US study aimed to evaluate the impact of a low-cost, reproducible “just in time” intervention on opioid prescribing in dialysis access operations. Standardised opioid prescribing guidelines were emailed to residents on the vascular service on the first day of the rotation. Opioid prescriptions were reviewed for four years before and one year after this intervention. The results showed a decrease in patients discharged with opioids following the intervention, from 58% to 36%. For patients prescribed opioids, the median quantity decreased from 90 to 45 oral morphine equivalents.
  2. Event
    This Grand Rounds session will cover three reports from the AHRQ Evidence-based Practice Center program focusing on making healthcare safer. Opioid stewardship interventions. Rapid response systems. Engaging family caregivers with structured communication for safe care transitions. Industry stakeholders will discuss the impact of these reports. Register
  3. News Article
    The continuing shortage of ADHD medication is causing those with the condition increasing stress and anxiety, the BBC has been told. Pharmacists said the problem persists despite a government assurance it would be resolved by the end of last year. In September, the Department for Health and Social Care (DHSC) blamed the UK-wide scarcity on "increased global demand and manufacturing issues". It said the disruption was "expected to resolve" between October and December. Lorraine Jukes, who has ADHD, said: "Here I am in April 2024, with only four days of medication left." The 36-year-old, from Iffley, Oxford, said she was "frantically phoning through lists of pharmacies" and being told there was no stock and no indication of any being available before she runs out. Oliver Picard, vice chair of the National Pharmacy Association, said: "We were told it would be resolved in December. "Some of the medication is starting to come back. In March, we had the supply of a certain brand of ADHD medication, we are now seeing shortages of other ADHD medication and we don't have a date for resupply. "Sometimes we can get some but will be limited to one packet per month pharmacy and that's not helpful either. It's hugely frustrating." Read full story Source: BBC News, 15 April 2024
  4. Content Article
    Patients with Parkinson’s are at risk of significant harm if they don’t get their medication on time, every time. ‘On time’ means within 30 minutes of the patient’s prescribed time. Even short delays can worsen symptoms such as rigidity, pain and tremors, increasing the risk of falls. Over half of people with Parkinson’s don’t get their medications on time, every time in hospital. This leads to worse patient outcomes, longer recovery times and increased costs to the NHS.
  5. News Article
    A man who suffered a psychotic episode which lasted for weeks was not fully informed about potential extreme side-effects of taking steroids medication, England’s health service Ombudsman has found. Andrew Holland was prescribed steroids in early January 2022 by Manchester Royal Eye Hospital after losing vision in his left eye and suffering a severe infection in his right eye. The 61-year-old from Manchester was given the medication as treatment for eye inflammation, but soon began suffering from disrupted sleep and severe headaches. These side-effects developed into more serious ones, including becoming aggressive, psychotic, and inexplicably wandering the street at different times of the day and night. After several hospital visits due to his symptoms, Andrew attended Manchester University NHS Foundation Trust’s emergency department in mid-January with a severe headache and later became an inpatient. He was diagnosed with steroid induced psychosis, with symptoms including hallucinations, insomnia and behaviour changes. Though no failings were found with Manchester University NHS Foundation Trust in prescribing Andrew with steroids for the eye condition, the Ombudsman discovered a missed opportunity to fully inform him of potential extreme side-effects. He was therefore unable to make a fully informed decision about whether to take them or not. The Trust apologised for an ‘unsatisfactory experience’. However, the Ombudsman found relevant guidelines were not followed. Moreover, there had been no acknowledgement of mistakes in communication about the side-effects. Nor was any attempt made to correct them. Read full story Source: PSHO, 10 April 2024
  6. Content Article
    Parkinson’s is the fastest growing neurological condition in the world. It can affect young or old, and in the UK, around 145,000 people are living with the condition. With population growth and ageing, this figure is estimated to increase by 20%, within the next ten years. At the moment, there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. People with Parkinson’s face a number of specific patient safety issues when accessing healthcare including communication difficulties and risks associated with medication delays. In this blog, Patient Safety Learning has pulled together 11 useful resources about Parkinson’s shared on the hub. They include guidance for patients and their families about hospital stays and medication, and awareness-raising resources for healthcare professionals about the patient safety issues people with Parkinson’s face.
  7. Content Article
    Clinical guidelines can contribute to medication errors but there is no overall understanding of how and where these occur. This study aimed to identify guideline-related medication errors reported via a national incident reporting system, and describe types of error, stages of medication use, guidelines, drugs, specialties and clinical locations most commonly associated with such errors.
  8. Content Article
    Batches of some products made by Legency Remedies Pvt Ltd have been found to contain a bacteria called Ralstonia pickettii (R. pickettii). All potentially affected batches are being recalled following an MHRA investigation.
  9. Content Article
    You may have heard about substandard or falsified syrup harming children and even causing deaths. There have been reports of falsified diabetes and weight loss treatments. How can you protect yourself? How does WHO keep you safe from substandard or falsified medical products? WHO’s Pernette Bourdillon Esteve explains in Science in 5.
  10. News Article
    Drugs are a cornerstone of medicine, but sometimes doctors make mistakes when prescribing them and patients don’t take them properly. A new AI tool developed at Oxford University aims to tackle both those problems. DrugGPT offers a safety net for clinicians when they prescribe medicines and gives them information that may help their patients better understand why and how to take them. Doctors and other healthcare professionals who prescribe medicines will be able to get an instant second opinion by entering a patient’s conditions into the chatbot. Prototype versions respond with a list of recommended drugs and flag up possible adverse effects and drug-drug interactions. “One of the great things is that it then explains why,” said Prof David Clifton, whose team at Oxford’s AI for Healthcare lab led the project. “It will show you the guidance – the research, flowcharts and references – and why it recommends this particular drug.” Read full story Source: The Guardian, 31 March 2024
  11. News Article
    Patients are dying needlessly every year due to vulnerable Britons with heart problems not being given antibiotics when they visit the dentist, doctors have said. Almost 400,000 people in the UK are at high risk of developing life-threatening infective endocarditis any time they have dental treatment, the medics say. The condition kills 30% of sufferers within a year. A refusal to approve antibiotic prophylaxis (AP) in such cases means that up to 261 people a year are getting the disease and up to 78 dying from it, they add. That policy may have caused up to 2,010 deaths over the last 16 years, it is claimed. That danger has arisen because the National Institute for Health and Care Excellence (NICE) does not follow international good medical practice and tell dentists to give at-risk patients antibiotics before they have a tooth extracted, root canal treatment or even have scale removed, the experts claim. The doctors – who include a professor of dentistry, two leading cardiologists and a professor of infectious diseases – have outlined their concerns in The Lancet medical journal. In it, they urge NICE to rethink its approach in order to save lives, citing pivotal evidence that has emerged since the regulator last examined the issue in 2015, which shows that antibiotics are “safe, cost-effective and efficacious”. Read full story Source: The Guardian, 2 April 2024
  12. Content Article
    This improvement initiative featured in the Journal of Patient Safety aimed to examine whether the independent double check (IDC) during administration of high alert medications resulted in improved patient safety when compared with a single check process. The authors found that IDC had no impact on reported medication events compared with single checking.
  13. Content Article
    Harm due to medicines and therapeutic options accounts for nearly 50% of preventable harm in medical care. This World Health Organization (WHO) policy brief is a resource for policy-makers, health workers, healthcare leaders, academic institutions and other relevant institutions to help understand the global burden of medication errors, address and prevent medication-related harm at all levels of healthcare, aligned with the strategic plan of the third WHO Global Patient Safety Challenge: Medication Without Harm. 
  14. News Article
    The US Supreme Court will hear oral arguments on whether to restrict access to mifepristone, a commonly used abortion pill. It is considered the most significant reproductive rights case since the court ended the nationwide right to abortion in June 2022. The Biden administration hopes the court will overturn a decision to limit access to the drug over safety concerns raised by anti-abortion groups. The pill has been legal since 2000. The current legal battle in the top US court began in November 2022 when the Alliance for Hippocratic Medicine, an umbrella group of anti-abortion doctors and activists, filed a lawsuit against the Food and Drug Administration, or FDA. The group claims that mifepristone is unsafe and further alleges that the federal agency unlawfully approved its use in September 2000 to medically terminate pregnancies through seven weeks gestation. Mifepristone is used in combination with another drug - misoprostol - for medical abortions, and it is now the most common way to have an abortion in the US. Medical abortions accounted for 63% of all abortions in 2023, up from 53% in 2020, according to the Guttmacher Institute. In total, more than five million US women have used mifepristone to terminate their pregnancies. Read full story Source: BBC News, 26 March 2024
  15. Content Article
    The Joint Commission has released a simplified breakdown of eight patient safety goals for US hospitals in 2024.
  16. Content Article
    Medication errors in ambulatory care settings present unique patient safety challenges. This systematic review explored the prevalence of medication errors in outpatient and ambulatory care settings. Findings indicate that prescribing errors (e.g., dosing errors) are the most common type of medication error and are often attributed to latent factors, such as knowledge gaps.
  17. Content Article
    The combination of emerging patient safety threats and the growing amount of published patient safety research, patient safety resources and accrediting body standards makes it increasingly difficult to prioritise adopting and implementing evidence-based practices. The US Agency for Healthcare Research and Quality's (AHRQ’s) fourth iteration of Making Healthcare Safer intends to address this issue by publishing evidence-based reviews of patient safety practices and topics as they are completed. This intentional release of updated reviews will aid healthcare organisation leaders in prioritising implementation of evidence-based practices in a timelier way. The report will also help researchers identify where more research is needed and assist policymakers in understanding which patient safety practices have the supporting evidence for promotion.
  18. News Article
    Children will no longer routinely be prescribed puberty blockers at gender identity clinics, NHS England has confirmed. The decision comes after a review found there was "not enough evidence" they are safe or effective. Puberty blockers, which pause the physical changes of puberty, will now only be available as part of research. It comes weeks before an independent review into gender identity services in England is due to be published. An interim report from the review, published in 2022 by Dr Hilary Cass, had earlier found there were "gaps in evidence" around the drugs and called for a transformation in the model of care for children with gender-related distress. Health Minister Maria Caulfield said: "We have always been clear that children's safety and wellbeing is paramount, so we welcome this landmark decision by the NHS. "Ending the routine prescription of puberty blockers will help ensure that care is based on evidence, expert clinical opinion and is in the best interests of the child." Read full story Source: BBC News, 13 March 2024
  19. Content Article
    Ashleigh Hughes is a Senior Sister at an NHS chemotherapy day unit. In this interview she shares her personal story about the impact of antibiotic underdosing on her Mum’s end of life care. Antibiotic underdosing is a medication safety issue that has profound implications for the health service as well as individual patients, but there is currently a lack of understanding and recognition of the issue.
  20. Content Article
    This annual report from ECRI and the Institute for Safe Medication Practices (ISMP) presents the top 10 patient safety concerns currently confronting the healthcare industry. It is a guide for a systems approach to adopting proactive strategies and solutions to mitigate risks, improve healthcare outcomes and enhance the well-being of patients and the healthcare workforce. Drawing on ECRI and ISMP’s evidence-based research, data and insights, this report sheds light on issues that leaders should evaluate within their own institutions as potential opportunities to reduce preventable harm. Some of the concerns represent emerging risks, some are well known but still unresolved, but all of them pertain to areas where organisations can make meaningful change.
  21. Community Post
    Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy? Was there an impact on your health (physical and mental)? Were you told the reason for it not being available? Was the issue resolved? If so, how long did it take? If you are still impacted by medication supply issues, have you been told when you will be able to access them again? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in the comments below. You'll need to register with the hub first, its free and easy to do. We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. What barriers and challenges have you seen around medication availability? Is there anything that can be done to improve wider systems or processes? Please comment below or email us at content@pslhub.org
  22. Content Article
    In this interview, we talk to Darren Powell, Clinical Lead for NHS England and Community Pharmacist, about medication supply issues. Darren shares his experiences of how medication shortages and tariffs are affecting patients and staff and offers insights into the complexity of the situation.  He tells us his thoughts on potential causes and barriers, as well as suggesting three actions for wider system safety. 
  23. Content Article
    This study aimed to determine whether the use of video telemedicine for paediatric consultations to referring hospital emergency departments (EDs) results in less frequent medication errors than the current standard of care—telephone consultations. The authors found no statistically significant differences in physician-related medication errors between children assigned to receive telephone consultations vs video telemedicine consultations.
  24. News Article
    MPs are calling for a new review into the dangers of the drug Primodos, claiming that families who suffered avoidable harm from it have been "sidelined and stonewalled". MPs said the suggestion there is no proven link between the hormone pregnancy test and babies being born with malformations is "factually and morally wrong". A report by the All-Party Parliamentary Group (APPG) on hormone pregnancy tests claims evidence was "covered up" and it is possible to "piece together a case that could reveal one of the biggest medical frauds of the 20th century". Around 1.5 million women in Britain were given hormone pregnancy tests between the 1950s and 1970s. They were instructed to take the drug by their GPs as a way of finding out if they were pregnant. But Primodos was withdrawn from the market in the UK in the late 1970s after regulators warned "an association was confirmed" between the drug and birth defects. However, in 2017 an expert working group found there was insufficient evidence of a causal association. But MPs now claim this report is flawed. It's hugely significant because the study was relied upon by the government and manufacturers last year to strike out a claim for compensation by the alleged victims. Read full story Source: Sky News, 1 March 2024
  25. News Article
    Opill, the first birth control pill approved for over-the-counter distribution, is now being shipped to retailers and pharmacies, the company behind the pill, Perrigo, announced on Monday. It will be available in stores and online later this month. The Food and Drug Administration approved Opill last year, paving the way for the United States to join the dozens of countries that have already made over-the-counter birth control pills available. Opill, which works by using the hormone progestin to prevent pregnancy, is meant to be taken every day around the same time and, when used as directed, is 98% effective. The pill’s arrival on shelves comes at a deeply fraught time for US reproductive rights: not only has the US supreme court demolished the national right to abortion, but the nation’s highest court is set to hear arguments over two abortion-related cases over the next few months. “Week after week, we hear stories of people being denied the reproductive health care they so desperately need because of politicians and judges overstepping into the lives of patients and providers. Today, we get to celebrate different news,” Dr Tracey Wilkinson, a pediatrician in Indiana and a board member with Physicians for Reproductive Health, said in a statement. “As Opill makes its way to pharmacies across the country, I am relieved to know that birth control access will become less challenging for so many people, but especially young people.” Read full story Source: The Guardian, 4 March 2024
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