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Showing results for tags 'Medication'.
Found 1,116 results
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Content ArticlePrescribing errors in general practice are an expensive, preventable cause of safety incidents, illness, hospitalisations and even deaths. Serious errors affect one in 550 prescription items, while hazardous prescribing in general practice contributes to around 1 in 25 hospital admissions. Outcomes of a trial published in the Lancet showed a reduction in error rates of up to 50% following adoption of PINCER. PINCER is a methodology for reducing medication errors and, thereby, improving medication safety. Using clinical audit tools alongside quality improvement methodology to review groups of patients taking high risk medicines/combinations of medicines, PINCER ensures that any risks are mitigated.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) investigated the case study of Martin, a 43-year old inmate, who suffered multiple seizures after his epilepsy medication wasn’t transferred with him to a new prison. Each day around 120 prisoners with ongoing medication needs are moved between jails. Martin’s case is just one example of a serious outcome when medication was missed. Prisoners may also need to be treated in the community at local hospitals, with prison security staff being taken away from planned duties to accompany them.
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The Oslo Medicines Initiative
Sam posted an article in Other countries and national agencies
The Oslo Medicines Initiative: “better access to effective, novel, high-priced medicines – a new vision for collaboration between the public and private sectors” is a new initiative of WHO/Europe, developed together with the Norwegian Ministry of Health and Care Services and the Norwegian Medicines Agency. The Initiative will provide a neutral platform for the public and private sectors to jointly outline a vision for equitable and sustainable access to effective, innovative and affordable medicines. -
Content ArticleThis Healthcare and Safety Investigation Branch (HSIB) report explores the under recognised toxicity of propranolol in overdose. Propranolol is used to treat a number of medical conditions, including migraine, cardiovascular problems and the physical effects of anxiety. The case that prompted the investigation was Emma, a 24-year old woman, took an overdose of both propranolol and citalopram (an antidepressant). She called an ambulance, but her condition quickly worsened. Despite resuscitation efforts from both paramedics and medical staff in the hospital she was transferred to, Emma sadly died. There has been a steady rise in the number of propranolol prescriptions issued to NHS patients. Between 2012 and 2017 there was a 33% increase in the number of deaths reported as being linked to propranolol overdose, with 52 deaths recorded as having been linked to propranolol overdose in 2017.
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Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the prescribing of medicines for children based on their weight. This HSIB investigation reviewed the case of a four-year-old child who was diagnosed with a blood clot in her leg following a surgical procedure in hospital. She was prescribed an anticoagulant medicine using an electronic prescribing and medicines administration (ePMA) system. Errors in the prescription, dispensing and administration processes meant that the child received ten times the intended dose on five separate occasions over three days. A scan of the child’s brain showed evidence of a bleed and she was admitted to the paediatric intensive care unit. Following three months in hospital, the child was discharged home with an ongoing care plan.
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Content ArticleThe first meeting of the Independent Medicines and Medical Device Safety Review (IMMDS) Patient Reference Group took place on Thursday 25th February. The website contains summaries of all the meetings.
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Content ArticleThis report by pharmaceutical company ViiV Healthcare focuses on results from wave two of their Positive Perspectives study. It investigates how people living with HIV (PLHIV) rate their own health and how living with HIV impacts their lives and affects their outlook for the future. It also examines their interactions and relationships with healthcare professionals and their experiences with antiretroviral treatment. The report highlights the importance of open and active dialogue and shared decision making between PLHIV and their healthcare professionals in improving outcomes.
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Content ArticleHappy Patient is a three-year project co-funded by the European Union, that seeks to reduce the impact of antimicrobial resistance (AMR) by decreasing the inappropriate use of antibiotics for the management of common community-acquired infection. Up to 25,000 people die every year in Europe as a direct consequence of the misuse of antibiotics, a figure that rises up to 30,000 in the United States (European Centre for Disease Prevention and Control). The Happy Patient Website offers a variety of communication tools for healthcare professionals and patients, including: Leaflet - Viruses or bacteria: What caused your infection? Urinary tract infections: A leaflet for older adults and their families Antibiotics prescription pad 5 myths about urinary tract infections (UTIs) in nursing home residents What you need to know if you have been prescribed an antibiotic
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Content ArticleOnline healthcare services and apps can help people take more control of their health, by getting access to care easily and when it suits them. This guidance for patients aims to help patients keep themselves safe when using online health services. Produced by a collaboration of UK health organisations, it includes six top tips for accessing healthcare online: Check if the online healthcare service and healthcare professionals working there are registered with UK regulators Ask questions about how the service works Answer questions honestly about your health and medical history Find out your options for treatment and how to take any medicines you’re prescribed Expect to be asked for consent for information to be shared with other healthcare professionals involved in your care Check what after-care you will receive
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World Health Organization: Patient engagement (December 2016)
Claire Cox posted an article in Patient engagement
This report is part of a technical series on safer primary care, published by the World Health Organization. The series explores the magnitude and nature of harm in the primary care setting from a number of different angles and provides some possible solutions and practical next steps for improving safety. The patient engagement report examines why it is important to involve people using services in improving safety and how this might best be done. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines. Some drugs, such as those used in anaesthesia and pain management, can cause patients to stop breathing. After administration, these drugs should be flushed through cannulae and extension lines to make sure no residual quantities of the drugs are left. Despite the issuing of multiple safety alerts over the past ten years, residual drugs in cannulae and extension line events continue to happen. When these events involve drugs that cause the patient to stop breathing, there is a risk of hypoxic brain injury (where the brain is damaged after a period where it does not get enough oxygen) or death. The investigation was launched after concerns were reported to HSIB by a consultant anaesthetist at a district general hospital where a patient had stopped breathing several hours after undergoing an anaesthetic. It’s thought that a quantity of the drug Suxamethonium - a muscle relaxant - was retained in their cannula after the procedure. The cannula containing the drug was flushed on the ward by a nurse preparing to administer intravenous paracetamol around three hours after the patient had returned from his procedure. The event was witnessed by a doctor who immediately started manual ventilation. The patient began to breathe spontaneously a few minutes later and suffered no physical harm. However, they have been left with a significant psychological impact following their experience of being awake but unable to move or breathe.
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Content Article"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
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Content ArticleSamantha Gould was 16 years old when she died by suicide due to an overdose of prescribed medication on 2 September 2018. She had borderline personality disorder that meant she was at risk of deliberate self-harm and suicide. In this report, the Coroner highlights concerns about a systemic weakness in the way in which Child and Adolescent Mental Health Services and primary care communicate with local pharmacies concerning 16-18 year old patients who are at risk of deliberate overdose. In spite of a safety plan agreed with Sam’s consultant psychiatrist whereby Sam’s parents would be responsible for her medication, Sam was able to pick up older prescriptions on 1 September 2018 without challenge, and it was those medications that were fatal in the combined amounts ingested by Sam.
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Content Article
At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. To mark World Antimicrobial Awareness Week, which takes place every year in November, we’ve selected ten resources related to antimicrobial resistance. Shared with us by hub members and patient safety advocates, they provide valuable insights and practical guidance about AMR. -
Content ArticleChildren born to women who take valproate during pregnancy are at significant risk of birth defects and persistent developmental disorders. As such, it is vital that women and girls are dispensed valproate safely. The General Pharmaceutical Council is reminding all pharmacy professionals of what they must do to ensure women and girls receive the right information about valproate and the risk of birth defects. The update includes
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
