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Content Article
Antibiotic Resistance & Patient Safety Portal
Claire Cox posted an article in International patient safety
The Antibiotic Resistance & Patient Safety Portal (AR&PSP) is an interactive web-based application that was created to innovatively display data collected through CDC’s National Healthcare Safety Network (NHSN), the Antibiotic Resistance Laboratory Network (AR Lab Network), and other sources. It offers enhanced data visualizations on Antibiotic Resistance, Use, and Stewardship datasets as well as Healthcare-Associated Infection (HAI) data. -
Content Article
Medicines safety: NHS online learning index
Claire Cox posted an article in Medication including labelling
This alphabetical index helps NHS staff with an interest in the safe use of medicines to quickly find e-learning or videos that have already been produced by the NHS, government agencies, or professional bodies. -
Content ArticleSteve Turner and colleagues have been working on ways to put people in charge of their own healthcare. Nowhere is this more important than for people with a variety of conditions or illnesses. Their approach involves people attending a group session on medicines, and then having the option of reviewing their medicines individually in a 3/4-hour session with two health professionals (e.g. a prescriber and a pharmacist). They provide people with their own notes in the form of a written action plan, which they can share with clinicians. Benefits identified to date include improved adherence with medicines; improved quality of life; reduced unnecessary medicines; identification and actions on previously unreported patient safety issues; a potential reduction in ‘bouncing’ referrals, less missing information and fewer unnecessary contacts with services. Steve explains more about Patient Led Clinical Education© and Patient Led Clinical Medicines Review™ in this blog.
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News Article
Report finds ‘profound failings’ in Scottish NHS IT systems
Patient Safety Learning posted a news article in News
A Scottish Government committee has found that the “profound failings” of IT systems are the biggest problem facing a medicine-prescribing service that does not sufficiently focus on patients. A report from the members of Scottish Parliament on the Health and Sport Committee describes a medicines system “burdened by market forces, public sector administrative bureaucracy and under resourcing, inconsistent leadership and a lack of comprehensive, strategic thinking and imagination, allied to an almost complete absence of useable data”. The committee particularly criticised the failure of the NHS to introduce appropriate IT systems. “We are extremely disappointed that once again all roads lead to the dismal failure of the NHS in Scotland to implement comprehensive IT systems which maximise the use of patient data to provide a better service,” the report says. Committee members are calling for an overhaul of the system to allow for collection and analysis of data that would ensure the best possible outcomes for patients and cost savings for the NHS. MSPs found a “lack of care” to understand patients’ experience of taking medicines and a lack of follow up to ensure that medicines were effective or even being used. Prescribers were “instinctively reaching for the prescription pad” and not taking the time to discuss medicines with patients, nor were the principals of realistic medicine, in which patients and clinicians share decision making about their care, being followed. Read full story Source: Public Technology.net, 1 July 2020 -
Content ArticleGood practice in prescribing opioid medicines for pain should reflect fundamental principles in prescribing generally. The decision to prescribe is underpinned by applying best professional practice; understanding the condition, the patient and their context and understanding the clinical use of the drug. Initiating, tapering or stopping opioid medicines should be managed in agreement with the patient and all members of their healthcare team.
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Content ArticlePresentation from Steve Turner at a NICE Associates Meeting on over prescribing of medication to patients with learning disabilities and reasonable adjustments. He highlights the death of Oliver McGowan and the lessons learnt.
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Content ArticleSafe and effective pharmacological management of acute and procedural pain in neonates, infants and early childhood requires understanding of age-related changes in both the pharmacokinetic and pharmacodynamic profile of analgesics. Evidence based clinical practice guidelines incorporate both pharmacological and non-pharmacological techniques that can have complementary roles in acute pain management. The knowledge, skills, and attitudes of paediatric pain physicians must be appropriate to the developmental stage and clinical state of the patient and also encompass the role of parents and/or carers.
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Content ArticleInvestigation of a complaint against the Belfast Health and Social Care Trust A Trust’s failure to perform an examination of a patient on admission to hospital meant he was not assessed by medical staff against this baseline during his time on the ward.
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Content ArticleThe World Health Organization Global Patient Safety Challenge, Medication Without Harm, aims to reduce serious, avoidable medication-related harm by 50% in 5 years, globally. Three areas have been identified for early priority action. This technical report addresses Medication Safety in Transitions of Care; why it is a priority, what has been done to address it to date and what needs to be done.
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Content ArticleThis website allows patients and professionals to report suspected side effects to medicines or medical device and diagnostic adverse incidents used in coronavirus treatment to the Medicines and Healthcare products Regulatory Agency (MRHA) to ensure safe and effective use. When reporting patients and healthcare professionals are encouraged to provide as much information as possible.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency issued this guidance following recent cases, including cases with fatal outcomes, in which patients have received the wrong medicine due to confusion between similarly named or sounding brand or generic names.
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Content ArticleThe existence of confusing drug names is one of the most common causes of medication error and is of concern worldwide. With tens of thousands of drugs currently on the market, the potential for error due to confusing drug names is significant. This includes nonproprietary names and proprietary (brand or trade-marked) names. Many drug names look or sound like other drug names. Contributing to this confusion are illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labelling, similar clinical use, similar strengths, dosage forms, frequency of administration, and the failure of manufacturers and regulatory authorities to recognise the potential for error and to conduct rigorous risk assessments for nonproprietary and brand names, prior to approving new product names This article from the WHO Collaborating Centre for Patient Safety Solutions looks at the issues and suggests actions.
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Content ArticleClinically focused presentation on Oliver's story from Steve Turner, given to the NICE Medicines & Prescribing Associates on 1 May 2019.
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Content ArticleInterventions information related to the patient’s medication and hospital stay is provided to the community pharmacists on discharge from hospital, who undertake a two-part service involving medicines reconciliation and a medicine use review. To investigate the association of this discharge medicines review (DMR) service with hospital readmission, a data linking process was undertaken across six national databases. The objective of this research, published by BMJ Open, was to evaluate the association of the DMR community pharmacy service with hospital readmissions through linking National Health Service data sets.
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News ArticleThe toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, a new report warns today. The Healthcare and Safety Investigation Branch (HSIB) report focuses on propranolol, a cardiac drug that is now predominately used to treat migraine and anxiety symptoms. It is highly toxic when taken in large quantities and patients deteriorate quickly, making it difficult to treat. The investigation highlighted that these risks aren’t known widely enough by medical staff across the health service, whether issuing prescriptions to at risk patients, responding to overdose calls or carrying out emergency treatment. Dr Stephen Drage, ICU consultant and HSIB’s Director of Investigations, said: “Propranolol is a powerful and safe drug, benefitting patients across the country. However, what our investigation has highlighted is just how potent it can be in overdose. This safety risk spans every area of healthcare – from the GPs that initially prescribe the drug, to ambulance staff who respond to those urgent calls and the clinicians that administer emergency treatment." The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose. Read full story Source: HSIB, 6 February 2020
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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 Article
Human medicines: highlights of 2019
Claire Cox posted an article in Medication including labelling
The European Medicines Agency (EMA) has published an PDF icon overview of its key recommendations in 2019 on the authorisation and safety monitoring of medicines for human use. Innovative medicines are essential to advancing public health as they bring new opportunities to treat certain diseases. In 2019, EMA recommended 66 medicines for marketing authorisation. Of these, 30 had a new active substance which had never been authorised in the EU before. The infographic includes a selection of medicines that represent significant progress in their therapeutic areas. Once a medicine is authorised by the European Commission and prescribed to patients, EMA and the EU Member States continuously monitor its quality and benefit-risk balance and take regulatory action when needed. Measures can include a change to the product information, the suspension or withdrawal of a medicine, or a recall of a limited number of batches. An overview of some of the most notable recommendations is also included in the document. -
Content ArticleA review on the extent of medication errors and recommendations to reduce medication-related harm in England. The Short Life Working Group report makes recommendations for a programme of work to tackle medication error and improve medicine safety.
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Content ArticleAntimicrobial resistance leads to increased morbidity, mortality and healthcare costs worldwide. In order to contain antimicrobial resistance, Antibiotic Stewardship Programs (ASP) have been developed to measure and improve the appropriateness of antimicrobial use. A common way to measure the appropriateness of antimicrobial use is by evaluating whether antimicrobials are prescribed according to local guidelines and if not available, to national or international guidelines.
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Content ArticleThe responsibility of anaesthetists in prescribing and administering controlled drugs has extended not only to the recovery room and intensive therapy unit, but also to acute and chronic pain services both in hospital and home care. These guidelines written by the Association of Anaesthetists recommend best practice for the safe preparation, distribution and disposal of controlled drugs to meet current clinical demands in peri-operative care.
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Content ArticleSteve Turner's blog discusses the use of psychotropic medicines for people with learning disabilities who show symptoms of distress. Steve offers a useful guide to help those prescribing these drugs consider all of the relevant factors so they can keep patients safe.
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News ArticleLloydsPharmacy is piloting an innovative new service that offers extra help and support to mental health patients. Funded by The National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), which is a partnership between The University of Manchester and Salford Royal, the pilot is being carried out in ten community pharmacies in Greater Manchester. The new service, referred to as AMPLIPHY, enables pharmacists to provide personalised support to people who have been newly prescribed a medicine for depression or anxiety, or those who have experienced a recent change to their prescription. The pilot programme has been funded and designed by researchers at the NIHR GM PSTRC in collaboration with LloydsPharmacy. Central to the programme is the ability for patients to lead the direction of support they receive. They set their own goals and objectives and the pharmacist supports them in these. Professor Darren Ashcroft, Deputy Director of the NIHR Greater Manchester PSTRC, said: "The NIHR Greater Manchester PSTRC focuses on improving patient safety across four themes, which include Medication Safety and Mental Health. AMPLIPHY covers two of these areas and we believe it has the potential to make a difference to patients, by providing enhanced support for their care in the community." The pilot is set to run until April 2020 when its impact will be evaluated before a decision is made on the next steps. Read full story Source: News-Medical.net, 22 January 2020
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News Article
Ways to identify EHR usability issues and reduce patient harm
Patient Safety Learning posted a news article in News
An electronic health record (EHR) bug that transmits and medication order for 25 mg of a drug – not the prescribed 2.5 mg – could be the difference between life and death. And it’s that seemingly impossible reality that’s bringing more industry stakeholders to the table working to better understand EHR usability and its effects on patient safety. “Often times when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, Director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence. “In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured. All of those things shape usability.” EHR usability issues are an exceptionally common issue, Ratwani reported in a recent JAMA article. About 40% EHRs reported having an issue that can potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting. Direct safety challenges typically come from EHR products that are sub-optimally designed, developed, or implemented. Usability issues stem from a very cluttered interface or a complex medication list. Seeing a cluttered list can lead to a clinician selecting the wrong medication. A major usability issue also comes from data entry. EHR users want that process to be as clean as possible. Consistency in the way information is entered is also key, Ratwani explained. Ratwani also wants to ensure that certification testing is as realistic as possible. He compared it to when a vehicle is certified to meet certain safety standards each year. This type of mechanism does not exist when it comes to EHRs because right when the product is certified, it then gets implemented, and there is no further certification of safety done at all after the initial testing. “One way to do that, at least for hospitals, is to have that process be something that the Joint Commission looks to do as part of their accreditation standards,” Ratwani said. “They could introduce some very basic accreditation standards that promote hospitals to do some very basic safety testing.” Read full story Source: EHR Intelligence, 13 January 2020 -
Content ArticleIn his blog, Steve Turner, Head of Medicines and Prescribing at Medicine Gov, talks about how to manage medicines in care homes and implement quality standards. This blog is designed to provide information for care homes and for those choosing a care home.
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Content ArticlePrescription drug errors are a leading source of harm in health care, resulting in substantial morbidity, mortality and healthcare costs estimated at more than $20 billion annually in the US. Currently, clinical decision support (CDS) alerting tools – computerised alerts and reminders – are widely used to identify and reduce medication errors. However, CDS systems have a variety of limitations, including that they are rule based and can identify only medication errors that have been previously identified and programmed into the alerting logic. A new study from Rozenblum et al., published in The Joint Commission Journal on Quality and Patient Safety, used retrospective data to evaluate the ability of a machine learning system – a platform that applies and automates advanced machine learning algorithms – to identify and prevent medication prescribing errors not previously identified by and programmed into the existing CDS system.
