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Found 1,093 results
  1. Content Article
    Since the 2007 landmark report on Preventing Medication Errors from the US National Academy of Medicine, effective interventions have been developed to address medication errors. Despite this, medication errors persist as the most common source of harm for patients worldwide. In this Editorial, Albert Wu looks at whether WHO's “The 5 Moments for Medication Safety” as a patient engagement tool has reached its intended audience.
  2. News Article
    Valproate-containing medicines will be dispensed in the manufacturer’s original full pack, following changes in regulations coming into effect on Wednesday 11 October 2023. The Medicines and Healthcare products Regulatory Agency (MHRA) has published new guidance for dispensers to support this change. Following a government consultation, this change to legislation has been made to ensure that patients always receive specific safety warnings and pictograms, including a patient card and the Patient Information Leaflet, which are contained in the manufacturer’s original full pack. These materials form a key part of the safety messaging and alert patients to the risks to the unborn baby if valproate-containing medicines are used in pregnancy. The changes follow a consultation on original pack dispensing and supply of medicines containing sodium valproate led by the Department of Health and Social Care (DHSC), in which there was overwhelming support for the introduction of the new measures, to further support safety of valproate-containing medicines. Minister for Public Health, Maria Caulfield, said: “This safety information will help patients stay informed about risks of valproate, and I encourage all dispensers of valproate to consult the new guidance carefully. “This continues our commitment to listening and learning from the experiences of people impacted by valproate and their families and using what we hear to improve patient safety.” Read full story Source: MHRA, 11 October 2023
  3. News Article
    The boss of Britain’s biggest medicines courier has been told to urgently improve its complaints system by the NHS ombudsman amid concerns patients let down by missing deliveries are repeatedly ignored. In a highly unusual development, Darryn Gibson, the chief executive of Sciensus, has received a written warning from Rob Behrens, the parliamentary and health service ombudsman (PHSO). It says patients “should not be ignored” and must be “listened to and taken seriously” or he will consider taking further action. The PHSO investigates complaints that have not been resolved by the NHS or by private providers of NHS care. Sciensus is the single largest provider of homecare medicines services to the NHS and has contracts worth millions of pounds. In an email seen by the Guardian, Behrens told Gibson he had been unable to investigate most reports received about Sciensus because patients had not been able to complete the company’s complaints process. “That is not acceptable or fair to complainants,” Behrens wrote. In a statement, Sciensus said it worked “very hard” to ensure NHS patients received their medicines on time. Its services had “a 95% satisfaction rating”, it added. The move follows a Guardian investigation that exposed how Sciensus put NHS patients at risk of harm with delayed, missed or botched deliveries of medicines for conditions including cancer, heart disease, diabetes, dementia and HIV. It also uncovered how patients’ alarm at vital drugs and medical devices not arriving at their home was often compounded by a struggle to reach Sciensus to complain and fix the problems. Read full story Source: The Guardian, 19 October 2023
  4. News Article
    A locum responsible pharmacist has been issued a warning after a patient died when he dispensed the wrong strength of oxycodone during a staffing crunch, the regulator has revealed. Paresh Gordhanbhai Patel supplied 120mg rather than the prescribed 20mg of oxycodone hydrochloride to an “elderly” patient while working two locum shifts as responsible pharmacist at Crompton Pharmacy at Whitley House Surgery in Chelmsford. After taking one tablet, the patient died from an “accidental” oxycodone “overdose”, the General Pharmaceutical Council’s (GPhC) fitness-to-practise (FtP) committee heard at a hearing held on 11-13 September. Mr Patel admitted that he was “stressed and overtired” when he failed to notice a “discrepancy” between the prescribed strength of oxycodone and what he ordered and dispensed, The regulator heard that Mr Patel was “over-conscientious” and felt compelled “at a human level” to help out at the under-staffed pharmacy, despite the fact that it was “not safe to do so”, it added. Mr Patel admitted that his errors “amounted to misconduct” and conceded to the committee that his fitness to practise was “impaired” because he “breached one of the fundamental principles of the pharmacy profession.” The regulator heard that Mr Patel had “immediately” admitted his mistake to the pharmacy and did so again at the coroner’s inquest, where he also publicly apologised to the patient’s family. Read full story Source: Chemist and Druggist, 12 October 2023
  5. News Article
    Health advocates in the USA are calling on the Biden administration to declare a public health emergency over a steep rise in congenital syphilis cases. The easily treated infection has quintupled in 10 years and can have harrowing impacts on children. Congenital syphilis happens when a baby contracts syphilis from its mother. Up to 40% of babies born to untreated mothers will be stillborn or die. Others can be left with severe birth defects such as bone damage, anaemia, blindness or deafness, and “neurological devastation”. “There is not a single baby that should be born in the US with syphilis,” David Harvey, the executive director of the National Coalition of STD Directors, told the Guardian. “We will be judged very severely as a country and a society for allowing this to happen to babies, when it is so easy to diagnose, treat and prevent this disease.” Rates of the disease have reached a nearly 30-year high just as supplies of the preferred medication, called Bicillin L-A, are in short supply. Syphilis can be cured with between one and three shots of the medication. Pfizer is the only manufacturer of the medication, a form of the first antibiotic ever synthesized, penicillin. The company said it does not expect shortages to be resolved before 2024, and blamed low supply partly on the increase in syphilis cases. Read full story Source: The Guardian, 17 October 2023
  6. News Article
    Several people have been admitted to hospital in Austria after using suspected fake versions of Novo Nordisk’s diabetes drug Ozempic, the country’s health safety body has said, the first report of harm to users as a European hunt for counterfeiters widened. The patients were reported to have suffered hypoglycaemia and seizures, serious side-effects that indicate that the product contained insulin instead of Ozempic’s active ingredient semaglutide, the health safety regulator Bundesamt für Sicherheit im Gesundheitswesen (BASG) said on Monday. The European Medicines Agency (EMA) warned last week that pens falsely labelled as Ozempic were in circulation, and Austria’s criminal investigation service said on Monday that the fake injection pens could still be in circulation. The Danish maker of the drug, Novo Nordisk, has warned of a rise in the online offers of counterfeit Ozempic as well as its weight-loss drug Wegovy, both based on semaglutide. “It appears that this shortage is being exploited by criminal organisations to bring counterfeits of Ozempic to market,” said BASG. Read full story Source: The Guardian, 24 October 2023
  7. News Article
    A new regional centre which promotes the reporting of suspected safety concerns associated with healthcare products has been launched in Northern Ireland. The Yellow Card centre for Northern Ireland will bring together a dedicated team to increase awareness, educate, and promote reporting of suspected adverse events to the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card scheme. The Yellow Card scheme provides a mechanism for patients, care givers and healthcare staff to report suspected safety concerns associated with healthcare products. Speaking at the launch of the new service, Northern Ireland Chief Pharmaceutical Officer Professor Cathy Harrison said: “Collecting and monitoring information on possible adverse effects of medications and healthcare products is vital to ensuring patient safety. "It is fitting that the launch of the Yellow Card centre for Northern Ireland coincides with World Patient Safety Day on 17 September, with this year’s theme of "Engaging patients for patient safety". "The Yellow Card scheme puts the patient voice at its heart. By voluntarily reporting issues, patients, families and care givers can play a crucial role in their own care, and the safety of healthcare as a whole. I welcome the launch of the new regional centre and would encourage anyone who has suspected safety concerns to report them.” Read full story Source: Department of Health (Northern Ireland), 13 September 2023
  8. News Article
    Patients with Parkinson’s disease are being put at risk when they have spells in hospital due to a lack of timely medication, according to a new report. Some 58% of people with Parkinson’s disease who were admitted to hospital in England last year said that they did not receive their medication on time during their stay. Parkinson’s UK said that medication for people with the condition is “time critical” and a delay of 30 minutes can mean the difference between functioning well and being unable to move, walk, talk or swallow. The charity also conducted freedom of information requests on English hospitals and found that one in four (26%) NHS trusts do not have policies that allow people with Parkinson’s to take their own medication in hospitals. Only half (52%) require staff responsible for prescribing and administering medication to have training on time critical medication, the charity found. Parkinson’s UK has called for a number of measures to be put in place to make sure patients in hospital can get access to medications when needed including: ensuring there are medication self-administration policies for patients where it is safe to do so; more training for staff and better use of e-prescribing to keep on track of medication timings. Read full story Source: The Independent, 19 September 2023
  9. Content Article
    Medication errors are a leading cause of patient harm globally. WHO launched the Global Patient Safety Challenge: Medication Without Harm, with the objective of preventing severe medication related patient harm globally. This publication is one of the documents in the WHO Technical Series on “Medication Safety Solutions” that the WHO is publishing, to address important aspects pertaining to medication safety.
  10. Content Article
    Alerts, recalls and safety information on medications from the Medicines and Healthcare products Regulatory Agency (MHRA)
  11. Content Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) are providing an update on a retrospective observational study on the risk to children born to men who took valproate in the 3 months before conception and on the need for the re-analysis of the data from this study before conclusions can be drawn. No action is needed from patients.  For female patients, healthcare professionals should continue to follow the existing strict precautions related to preventing the use of valproate in pregnancy (Valproate Pregnancy Prevention Programme).
  12. Content Article
    World Patients Alliance is the umbrella organisation of patients and patients’ organisations around the globe. They seek to ensure that all patients have access to safe, high quality, and affordable healthcare everywhere in the world. These videos produced by World Patients Alliance provide information for patients on the following topics: How do you talk to your healthcare provider? An introduction to medication safety How many medications are too many?
  13. News Article
    Children are not being over-diagnosed with ADHD despite concerns about a spike in prescriptions of powerful stimulant drugs, a leading psychiatrist has said. NHS statistics show 125,000 children and teenagers in England are taking drugs such as Ritalin for symptoms such as poor concentration, up by a quarter since before the Covid pandemic. Isobel Heyman, a consultant child and adolescent psychiatrist at Great Ormond Street Hospital and lead for child mental health at Cambridge Children’s Hospital, said that on the whole ADHD remained “under-treated” and that this was driving high levels of mental illness in young people. Speaking to the Times Health Commission, Heyman said: “My understanding is that the increase in prescribing is largely related to increased diagnosis and increased recognition … We are still overall slightly under-treating [rather] than over-treating. “There is a problem about over-medicalisation of ordinary distress, ordinary ebullience and over-enthusiasm in young people.” She said the public should be reassured that ADHD diagnoses follow a “very stringent” process. However, she said private adult ADHD clinics may be less “rigorous” in providing a diagnosis. Read full story (paywalled) Source: The Times, 18 October 2023 Further reading: Long waits for ADHD diagnosis and treatment are a patient safety issue
  14. Content Article
    Orchard Care Homes had noticed high numbers of antipsychotic medicines being prescribed to people living with dementia. There appeared to be little consideration of why these people were distressed and communicating this through behaviour. Orchard staff were convinced pain was a key factor in these distress responses—they were not necessarily because the person had a diagnosis of dementia. Orchard adopted PainChek, a digital pain assessment tool, in 2021 to support their dementia promise framework. They worked with the PainChek team and ran a pilot with the app. They were one of the first care providers to use this solution in the UK. It was originally launched it in one of their specialist dementia care communities, but is now in all 23 Orchard homes. Since the rollout of the app, there has been an increase in available pain relief and a decrease in conflict-related safeguarding referrals. There is increased time available for colleagues and a reduction in polypharmacy. There has been a 10% decrease in antipsychotic medicine use across all 23 homes, promoting a greater quality of life. People now have effective pain management plans. Orchard have also been able to ensure distress plans are in place which firstly considers if pain is the cause of distress. This case study was submitted to the Care Quality Commission's (CQC's) Capturing innovation to accelerate improvement project by Orchard Care Homes.
  15. Content Article
    This is guidance for dispensing of valproate-containing medicines in the manufacturer’s original full pack, following amendments to the Human Medicines Regulations (HMRs). These amendments currently apply in England, Scotland and Wales. This guidance should be regarded as good practice by pharmacists in Northern Ireland. The change comes into force in England, Scotland and Wales from 11 October 2023. 
  16. Event
    Medication errors are a leading cause of patient harm globally. Look-alike, sound-alike (LASA) medicines are a well-recognised cause of medication errors that are due to orthographic (look-alike) and phonetic (sound-alike) similarities between medicines, which can be confusing. Look-alike medicines appear visually the same with respect to packaging, shape, colour and/or size, while sound-alike medicines are similar in the phonetics of their names, doses and/or strengths. Confusions can occur between brand-brand, brand-generic or generic-generic names. Organisations need to prospectively design and implement strategies to identify LASA medication errors and build a robust system that intercepts them before they result in patient harm. At this webinar, WHO will launch their publication “Medication Safety for Look-alike, Sound-alike Medicines”, as part of the WHO technical series on “Medication Safety Solutions”. Preventive strategies that can be implemented by healthcare professionals and organizations will be discussed on how to prevent LASA errors to reduce the risk of medication-related harm. Register
  17. Content Article
    Information from ADHD on the elvanse and atomoxetine drug shortage and what you should do.
  18. Content Article
    This year, WHO's World Mental Health Day on 10 October will focus on the theme 'Mental health is a universal human right'. To mark World Mental Health Day, we’ve pulled together 10 resources, blogs and reports from the hub that focus on improving patient safety across different aspects of mental health services.
  19. Content Article
    Most pharmaceutical products can cause adverse consequences of varying severity and frequency. Authors of this article, published by Drug Safety, look at issues relating to the monitoring the safety of over the counter medicines.
  20. News Article
    ADHD patients around the UK are finding they can't get hold of medication since a national shortage was announced. Three different medicines are affected, and the government says some supply issues could last until December. The Department for Health and Social Care (DHSC) says "increased global demand and manufacturing issues" are behind the shortages. Medication helps to manage symptoms, which can include difficulty concentrating and focusing, hyperactivity and impulsiveness. Dr Saadia Arshad, a consultant psychiatrist, who specialises in diagnosing and treating people with ADHD. She says the shortage of medication is "not a new issue, but it's a recurring one". Dr Saadia says suddenly stopping meds can lead to patients "feeling jittery, finding it difficult to pay attention, staying focused and feeling restless". Even though she understands the shortage can be worrying, Dr Saadia says it's important that people don't take measures into their own hands. "These medicines can be quite potent and the response to medication for two individuals is not the same," she says. "So please do not take any action without discussing it with your clinician." Read full story Source: BBC News, 6 October 2023
  21. Event
    This conference focuses on improving practice and patient safety to reduce Extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce Extravasation Injury Learn from outstanding practice in recognizing, treating and escalating extravasation injury Reflect on national developments and learning Ensure vesicants are administered in the safest way Develop your skills in training frontline staff to recognize evolving injuries Understand how you can implement preventative measures Identify key strategies for improvement Educate patients to raise alarm and improve consent procedures Develop protocols to support practice Understand the role and competencies of the NHS trust lead for extravasation Ensure effective treatment, and early intervention in severe wounds Learn from case studies in cancer, maternity, radiology and paediatrics Ensure you are up to date with the latest legal cases Self assess and reflect on your own practice Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  22. Content Article
    These videos posted by Melissa Sheldrick tell the story of her son Andrew, who died aged eight from a medication error. The investigation into Andrew's death found that he had been given baclofen by his pharmacy instead of the tryptophan he had been prescribed. When tested, the dose of baclofen in the bottle given to Andrew contained three times the lethal dose of baclofen for adults. PSMF Melissa's story. In this video, Andrew's mother Melissa talks about what happened to Andrew and how it led to her campaigning for mandatory reporting of medication errors by pharmacists across Canada, Australia and the US. Patients taking the lead: Collaborating for safer healthcare. This presentation was originally given at the World Health Organization's (WHO's) World Patient Safety Day conference on 12 September 2023 in Geneva, Switzerland. Melissa tells Andrew's story and talks about how she has raised awareness of gaps in accountability for pharmacies and pharmacists. She describes how she was invited to be part of a taskforce to improve safety in pharmacy by the pharmacy regulator in her home state of Ontario—this was the first time a member of the public had been included in such a taskforce.
  23. News Article
    Prescribers should not start any new patients on some ADHD medicines because of a national shortage, the Department for Health and Social Care has warned. GPs are also being asked to identify and contact all patients currently prescribed the medicines to ensure they have supplies to last. A national patient safety alert said there were ‘supply disruptions’ of various strengths of methylphenidate, lisdexamfetamine and guanfacine. It follows a previous alert about shortages of atomoxetine capsules in August which is set to resolve next month, DHSC said. The shortages are due to a combination of manufacturing issues and an increased global demand, the alert explained. With the latest issues expected to continue to December for some medicines, new patients should not be started on the products affected by shortages until the supply issue resolves, the guidance sent to healthcare professionals said. Where patients do not have enough to last until the re-supply date – which differs depending on the medicine in question – GPs are being asked to contact pharmacies to find out about stocks and reach out to the patient’s specialist team for advice if a product cannot be sourced. Read full story Source: Pulse, 28 September 2023
  24. Content Article
    There are supply disruptions affecting various strengths of the following medications which are licensed for the treatment of attention deficit hyperactivity disorder (ADHD): methylphenidate (Equasym® XL) capsules, methylphenidate (Xaggitin XL® , Concerta XL® , Xenidate XL® ) prolonged-release tablets, lisdexamfetamine (Elvanse® ) capsules, and guanfacine (Intuniv® ) prolonged-release tablets. This is a safety critical and complex National Patient Safety Alert. Implementation should be co-ordinated by an executive lead (or equivalent role in organisations without executive boards) and supported by clinical leaders in pharmacy, community pharmacy, GP practices, mental health services and those working in the health and justice sector.
  25. Content Article
    If you are throwing up, having diarrhoea, drinking less water and/or have a fever, you can become dehydrated. Being dehydrated means your body doesn't have enough fluids. When you're dehydrated, some medications used to treat certain health problems may cause unwanted side effects, such as harm to your kidneys. It is important to have a plan to prevent these side effects in case you should become sick and dehydrated. The authors of this guidance learned about a person who died in hospital as a result of side effects of taking a particular medication while dehydrated. They were taking a diabetes medication called empagliflozin and kept taking the same dose after becoming sick. This medication is helpful for people with diabetes, but it can cause serious side effects if it's taken when the person is dehydrated. This guidance offers advice on how to reduce the risk of side effects from your medications when you are sick and dehydrated.
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