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Content ArticleIf 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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News Article
Millions wrongly labelled with penicillin allergy, pharmacists warn
Patient Safety Learning posted a news article in News
Millions of people wrongly believe they are allergic to penicillin, which could mean they take longer to recover after an infection, pharmacists say. About four million people in the UK have the drug allergy on their medical record - but when tested, 90% of them are not allergic, research suggests. The Royal Pharmaceutical Society says many people confuse antibiotic side-effects with an allergic reaction. Common allergic symptoms include itchy skin, a raised rash and swelling. Nausea, breathlessness, coughing, diarrhoea and a runny nose are some of the others. But antibiotics, which treat bacterial infections, can themselves cause nausea or diarrhoea and the underlying infection can also lead to a rash. And this means people often mistakenly believe they are allergic to penicillin, which is in many good, common antibiotics. These are used to treat chest, skin and urinary tract infections - but if people are labelled allergic, they are given second-choice antibiotics, which can be less effective. Read full story Source: BBC News, 28 September 2023 -
Content ArticleStandardising community pharmacy information so it can be shared digitally should reduce the burden on GPs and lead to safer, more personalised care, writes Stephen Goundrey-Smith. The Professional Record Standards Body’s (PRSB) Community Pharmacy Standard enables information to be recorded in the community pharmacy and sent to the person’s GP and all the services covered by the England Community Pharmacy Contractual Framework. Having access to better information will allow the community pharmacy team to take on a greater range of clinical services and reduce the burden on GPs and other parts of the health and care system. It will also raise the profile of the clinical contribution that community pharmacists make to the wider NHS.
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Content ArticleMelissa Sheldrick is a Patient Safety Expert, Patient and Family Advisor at ISMP Canada and member of Patients for Patient Safety Canada. With a passion for improving medication safety for all, Melissa uses her unique perspective as a caregiver with lived experience to drive change and promote a culture of safety within the healthcare system. Her dedication to this work is inspired by her personal experience as a mother who lost her 8-year-old son Andrew to a medication error in 2016. This is their story.
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Content ArticleIn this article, Sharon Hartles highlights the high-profile legal battle involving numerous Primodos-affected claimants against pharmaceutical companies and the government. The court ruled against the claimants, dismissing their claims related to hormone pregnancy tests and foetal harm. This decision led to disappointment and criticism from advocates, MPs, and academics involved in the Primodos scandal. Sharon Hartles is affiliated with the Risky Hormones research project, which is an international collaboration in partnership with patient groups. Additionally, she is a member of the Harm and Evidence Research Collaborative at the Open University. Related reading on the hub: Primodos 2023: The fight for justice continues for the Association for Children Damaged by Hormone Pregnancy Tests Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response Primodos: The next steps towards justice Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests
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News Article
Primodos: Pregnancy test damages claims thrown out by judge
Patient Safety Learning posted a news article in News
Claims for damages by more than 170 people who say they were affected by hormone-based pregnancy test drugs have been thrown out by a High Court judge. The drugs, including Primodos, were given to women to test if they were pregnant from the 1950s to 1970s and alleged to have caused birth defects. But the judge ruled there was no new evidence linking the tests with foetal harm and "no real prospect of success". Campaigners say they are "profoundly disappointed" with the judgement. Legal action had been brought against three drug companies - Bayer Pharma, Schering Health Care, Aventis Pharma - as well as the government in a bid for compensation. However, they argued there was no evidence of a "causal association" between the hormone pregnancy tests and the harm suffered by the claimants. Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests, said she was "profoundly disappointed" with the judgement. "We do not accept the defendants' claim that our evidence did not provide sufficient scientific evidence and look forward to the additional scientific evidence, to support our original argument, which is due to be published shortly," she added. Read full story Source: BBC News, 28 May 2023 Further reading on the hub: Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests -
Content ArticleThe Department of Health and Social Care is consulting jointly with the Department of Health Northern Ireland to seek your views on amending the Human Medicines Regulations 2012 to enable pharmacy technicians to supply and administer medicines using patient group directions (PGDs). This proposal supports the ambitions of NHS systems across the UK to maximise the use of the skill mix within pharmacy teams, enabling them to meet more of the health needs of their local populations. Deadline: 29 September 2023.
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Content ArticlePeople rely on prescription medication to treat and manage their conditions and keep well. Based on analysis of public feedback from local Healthwatch and from a webform on pharmacies, this blog by Healthwatch England highlights the challenges people face when trying to get prescription medication. It outlines the following key issues: Shortages of medication Delays in getting repeat prescriptions issued Shortages of staff Closed pharmacies
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Content Article
Patient Safety Commissioner initiatives
Patient Safety Learning posted an article in England
Patients need to be involved in all aspects of the design and delivery of healthcare and to make quality improvements that prevent harm. The Patient Safety Commissioner website shows examples of where working in partnership with patients and families, listening to patients’ voice and acting upon their concerns have made positive changes. -
Content Article
This opinion piece is by Luke* who suffers from post-SSRI sexual dysfunction (PSSD) after he was prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. Luke introduces the condition, drawing on the experiences that others have shared through PSSD communities, to highlight the devastating impact on patients. He calls for widespread recognition, improved risk communication and better support for sufferers. *Name has been changed- Posted
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Content ArticleIn this podcast episode, Rosie, Sean, Carlton, and Emily share their experiences with Post-SSRI Sexual Dysfunction (PSSD), a condition where individuals face persistent sexual side effects and other side effects after taking or discontinuing certain antidepressants. Throughout the conversation, they emphasise the need for increased awareness and research on PSSD, sharing personal stories to shed light on this often-overlooked condition. Despite the challenges they face, they remain determined to advocate for recognition and support for those suffering from PSSD.
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Content Article
People with Parkinson’s need their medication on time every time. Yet over half of people with the condition don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death. Parkinson's UK are campaigning to make sure that no one with Parkinson’s is worried that they will leave hospital more unwell than when they went in. Whether you have Parkinson’s, support someone who does, work in the health and care system or campaign to improve it, you can take action to make hospitals and care homes safer. Together we can get more people to understand how big this problem is. And we can put pressure on the right people, across the UK, to change hospital policies, improve prescribing in hospitals and make sure staff are trained to give time critical medication. -
Content ArticleSexual dysfunction is a common side effect of Serotonergic antidepressants (SA) treatment, and persists in some patients despite drug discontinuation, a condition termed post-SSRI sexual dysfunction (PSSD). The risk for PSSD is unknown but is thought to be rare and difficult to assess. This study, published in the Annals of general psychiatry, aims to estimate the risk of erectile dysfunction (ED) and PSSD in males treated with SAs.
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Content ArticleA set of enduring conditions have been reported in the literature involving persistent sexual dysfunction after discontinuation of serotonin reuptake inhibiting antidepressants, 5 alpha-reductase inhibitors and isotretinoin. The objective of this study, published by the International Journal of Safety and Risk in Medicine, was to develop diagnostic criteria for post-SSRI sexual dysfunction (PSSD), persistent genital arousal disorder (PGAD) following serotonin reuptake inhibitors, post-finasteride syndrome (PFS) and post-retinoid sexual dysfunction (PRSD).
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Content ArticleThis is the first in a series of podcasts NHS England has produced to mark World Patient Safety Day 2023, and celebrate its theme of ‘engaging patients for patient safety’. The series features some of the Patient Safety Partners that work with the National Patient Safety Team, who play a vital role in providing a patient’s perspective to support our work to improve patient safety. In this podcast, Graham, who became a patient safety partner in 2020, shares his insights on the benefits of involving patients and why he feels it is so important in supporting the NHS to improve patient safety, and talks about his experience as a patient safety partner, particularly working to co-design elements of the medical examiner and medicines safety improvement programmes.
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Content ArticleThe Patient Safety Network (PSNet) produces primers which provide guidance on key topics in patient safety through context, epidemiology and relevant PSNet content. This primer focuses on nurse-related medication administration errors and highlights that despite error reduction efforts through implementing new technologies and streamlining processes, medication administration errors remain prevalent. It covers the background to the issue, low-tech and high-tech prevention strategies and the current context.
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News Article
Patients feel misled by pledge of cannabis on NHS
Patient Safety Learning posted a news article in News
A high-profile government climbdown which legalised a type of cannabis medicine on the NHS five years ago misled patients, campaigners say. It was thought the law change would mean the unlicensed drug, which treats a range of conditions, could be freely prescribed by specialist doctors. But fewer than five NHS patients have been given the medicine, leaving others to either pay privately or miss out. The government says safety needs to be proven before a wider rollout. Legalisation of whole-cannabis medicine was hailed as a breakthrough for patients - giving either NHS or private specialist doctors the option to prescribe it if they believed their patients would benefit. But patients are being turned away, say campaigners, because doctors often do not know about the medicine, which is not on NHS trusts' approved lists. Some specialists who do know about it say there is insufficient evidence of the drug's safety and benefits to support prescribing. Senior paediatric consultant Dr David McCormick, from King's College Hospital in London, says it was "disingenuous" of the government to suggest in 2018 that NHS prescribing was ready to take place. "Parents were clamouring at our door, or phoning all the time, as they believed we were able to prescribe and that was not the case. "The message went out, 'doctors can now prescribe cannabis products' and that put us in a difficult position, because in truth we need to apply for that to be approved by NHS England." Read full story Source: BBC News, 13 September 2023 -
Content ArticleHealthcare professionals prescribing fluoroquinolone antibiotics (ciprofloxacin, delafloxacin, levofloxacin, moxifloxacin, ofloxacin) are reminded to be alert to the risk of disabling and potentially long-lasting or irreversible side effects. Do not prescribe fluoroquinolones for non-severe or self-limiting infections, or for mild to moderate infections (such as in acute exacerbation of chronic bronchitis and chronic obstructive pulmonary disease) unless other antibiotics that are commonly recommended for these infections are considered inappropriate. Fluoroquinolone treatment should be discontinued at the first signs of a serious adverse reaction, including tendon pain or inflammation.
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EventuntilWorld Patient Safety Day, observed annually on 17 September, aims to raise global awareness about patient safety and calls for solidarity and united action by all countries and international partners to reduce harm to patients. Patient and family engagement is one of the main strategies to eliminate avoidable harm in healthcare and ‘Engaging Patients for Patient Safety’ is the defining theme for World Patient Safety Day 2023. Access to safe, quality, and affordable medicines and their correct administration and use is critical for patient treatment and satisfaction. However, harm from medication treatment, including that resulting from a medicine shortage, in hospitals is common. 80 million people in Europe report experiencing a serious medication error during hospitalisation. With the outcomes of enhanced pharmacovigilance practices on medication safety practices in hospitals unclear and widespread deployment and adoption of digitalisation that can contribute to medication safety lagging, error reporting remains one of the most effective strategies to improve patient safety from medication harm. The 72nd World Health Assembly affirms that informed patients and carers could support the elimination of avoidable harm during care delivery. However, in many cases, patients nor their families are unaware of what systems are available to report the error. Therefore, awareness, access and use of patient-centred, user-friendly, reporting systems, will strengthen the evidence base that medication errors are not an unfortunate occupational hazard in healthcare delivery. This webinar will raise awareness of the importance of all stakeholders engaging with patients to improve medication safety in hospitals. It will discuss the importance of ensuring that patients are informed about medication safety and know how to report an unintended medication error when it occurs. Register
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News Article
'I will never be the same': RaDonda Vaught speaks out after sentencing
Patient Safety Learning posted a news article in News
RaDonda Vaught has spoken out about her criminal case for the first time last week in an exclusive interview with ABC News. Ms. Vaught, 38, was sentenced to three years of supervised probation on 13 May. She was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. The error, in which vecuronium, a powerful paralyser, was administered instead of the sedative Versed, led to the death of 75-year-old Charlene Murphey. "I will never be the same person," Ms. Vaught told ABC News, "It's really hard to be happy about something without immediately feeling guilty. She could still be alive, with her family. Even with all the system errors, the nurse is the last to check." Ms. Vaught immediately took responsibility for the medication error after it occurred but contends that her actions alone did not cause the error. Her case has spurred an outcry from nurses across the country, many of whom have expressed concerns about the likelihood of similar mistakes under increasingly difficult working conditions. "So many things had to line up incorrectly for this error to have happened, and my actions were not alone in that," Ms. Vaught said. When Ms. Pilgrim asked her if she felt like a scapegoat, Ms. Vaught said, "I think the whole world feels like I was a scapegoat." "There's a fine line between blame and responsibility, and in healthcare, we don't blame," she said. "I'm responsible for what I failed to do. Vanderbilt is responsible for what they failed to do." Read full story Source: Becker's Hospital Review, 23 May 2022 -
News Article
NHS doctors to stop issuing prescriptions for 35 minor medical conditions
Patient Safety Learning posted a news article in News
THE NHS has announced plans to scrap prescriptions for 35 conditions in a bid to save the money it spends on drugs available over-the-counter (OTC). The body said it will no longer issue treatments for a range of minor conditions, such as diarrhoea, oral thrush and ailments associated with pain. The health body will no longer prescribe drugs for 35 conditions listed below, which patients will have to purchase from their local pharmacy or supermarket going forward. The plan to dial back on prescriptions was devised with the aim of allocating funds to treatments for more serious conditions, according to the health body. Many of the conditions are able to resolve on their own, but prescriptions may still be issued if an exemption applies. Acute sore throat Conjunctivitis Coughs, colds, and nasal congestion Cradle cap Dandruff Diarrhoea Dry eyes / sore tired eyes Earwax Excessive sweating Haemorrhoids Head live Indigestion and heartburn Infant colic Infrequent cold sores of the lip Infrequent constipation Infrequent migraine Insect bites and stings Mild acne Mild burns and scalds Mild cystitis Mild dry skin Mild irritant dermatitis Mild to moderate hay fever Minor conditions associated with pain, discomfort and fever (e.g. aches and pain, headache, period pain, back pain) Mouth ulcers Nappy rash Oral thrush Prevention of tooth decay Ringworm/athlete’s foot Sunburn Sun protection Teething / mild toothache Threadworms Travel sickness Warts and verrucae Read full story Source: Express, 20 May 2022 -
News Article
Injured women face discrimination over life-saving drugs, say researchers
Patient Safety Learning posted a news article in News
Injured women are experiencing sex discrimination in the administration of a life-saving drug that cuts the risk of bleeding to death by 30%, researchers have warned. They found that female trauma victims were half as likely to receive tranexamic acid (TXA) as injured men – even though the treatment is equally effective regardless of sex. “These results are very concerning. TXA is the only proven life-saving treatment for traumatic bleeding. Women were treated less frequently than men regardless of their risk of death from bleeding or the severity of their injuries,” said Prof Ian Roberts of the London School of Hygiene and Tropical Medicine (LSHTM), who was involved in the study. “This looks like sex discrimination, and there is an urgent need to reduce this disparity, so all patients who need the drug have the chance to receive it.” “Whatever of the mechanism of injury, and whatever the bleeding risk we looked at, women were statistically less likely to receive tranexamic acid than men, apart from road traffic collisions with a very high risk of bleeding,” said Tim Nutbeam, whose research was published in the British Journal of Anaesthesia. “However, when we looked at mechanisms of injury which we tend to associate less with major trauma, such as falls from standing, women and particularly older women were much less likely to receive it.” As striking as these results are, they are not necessarily surprising, he added: “It is already known that women with chest pain are less likely to receive aspirin, less likely to be resuscitated for out of hospital cardiac arrest, and less likely to be taken to hospital by an ambulance using lights and sirens.” Read full story Source: The Guardian, 18 May 2022 -
News ArticleRaDonda Vaught was sentenced to three years of supervised probation on the 13 May for a fatal medication error she made in 2017 while working as a nurse at the Vanderbilt University Medical Center in the USA. In remarks made during the sentencing hearing, Ms. Vaught expressed concerns over what her case means for clinicians and patient safety reporting. "This sentencing is bound to have an effect on how [nurses] proceed both in reporting medical errors, medication errors, raising concerns if they see something they feel needs to be brought to someone's attention," she said. "I worry this is going to have a deep impact on patient safety." Numerous medical organisations expressed similar concerns in statements circulated after Ms. Vaught's sentencing. "To achieve our goal of zero patient harm and death from preventable medical errors, we need to foster a culture where leadership of hospitals and healthcare organizations support healthcare workers and encourage them to share near misses," the Patient Safety Movement Foundation said in a statement. "Healthcare workers are human and healthcare systems need to ensure there are appropriate processes in place to provide their staff with a safe and reliable working environment so they can provide their patients with the best care. Only by identifying potential problems and learning from them can change occur." Read full story Source: Becker's Hospital Review, 16 May 2022
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News Article
NHS prescription charges in England to be frozen
Patient Safety Learning posted a news article in News
NHS prescription charges in England are to be frozen for the first time in 12 years, the government has confirmed. Single prescription charges, which the Department of Health said would normally rise "in line with inflation", will remain at £9.35 until next year. Health Secretary Sajid Javid said freezing the costs would "put money back in people's pockets". Faith Angwet, a single mother of two, said she had to choose between paying for prescriptions to treat for her high blood pressure, or using that money to feed her children. She said the price freeze "won't go far" because "it's not necessarily the outgoings affecting me, everything is going up in price and I'm not able to afford everything I use to be, including my prescription". Claire Anderson, of the Royal Pharmaceutical Society, said people who do not qualify for free prescriptions because of their income, age, or medication type, often had to make decisions about which medicines they need. "Those medicines are prescribed for a reason because that patient needs that treatment," she told the BBC. And Laura Cockram, chairwoman of the Prescription Charges Coalition, who welcomed the freeze, said the government should review the list of those who qualified for free prescriptions. She said the prescription exemption charge list was put together more than 50 years ago, when conditions like HIV "didn't even exist" and at a time there "weren't life saving treatments for things like asthma, Parkinson's and MS". Read full story Source: BBC News, 16 May 2022 -
News ArticleWomen and babies in the UK are “dying needlessly” because of a lack of suitable medicines to use in pregnancy, according to a report that calls for a radical overhaul of maternal health. A “profound” shortage of research and the widespread exclusion of pregnant and breastfeeding women from clinical trials means hardly any new drugs are approved for common medical problems in pregnancy or soon after childbirth, the report finds. Meanwhile, scarce or contradictory information about the safety of existing medicines women may be taking for continuing conditions can make it impossible to reach a confident decision on whether or not to continue them in pregnancy, the experts add. “While pregnancy in the UK is generally considered safe, women and babies are still dying needlessly as a direct result of preventable pregnancy complications,” the authors say. Each year, 5,000 babies in the UK are either stillborn or die shortly after birth, while about 70 women die of complications in pregnancy. The Healthy Mum, Healthy Baby, Healthy Future report draws on evidence from patient groups, clinicians, researchers, lawyers, insurance specialists and the pharmaceutical industry, it proposes “urgent” changes to transform women’s access to modern medicine. The report highlights the “profound lack of research activity” and up-to-date information that leaves pregnant women and their physicians in the dark about whether to continue with certain medicines in pregnancy. Some epilepsy drugs, for example, can increase the risk of birth defects, but coming off them can put the woman at risk of severe seizures, which can also harm the baby. Lady Manningham-Buller said the situation “urgently needs to change”, with the report setting out eight recommendations to prevent needless deaths. Read full story Source: The Guardian, 12 May 2022
