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News Article
Overprescribing of medicines must stop, says government
Patient Safety Learning posted a news article in News
Many patients are being prescribed unnecessary and even harmful treatments, a new report warns. The review, in England, suggests one-tenth of items dispensed by primary care are inappropriate or could be changed. Around 15% of people take five or more medicines a day - some are to deal with the side-effects of the others. The government is appointing a prescribing tsar to help with the issue and stop waste. Overprescribing can happen when: a better alternative is available but not given the medicine is appropriate for a condition but not the individual patient a condition changes and the medicine is no longer appropriate the patient no longer needs the medicine but continues to be prescribed it. Chief pharmaceutical officer for England, Dr Keith Ridge, said: "Medicines do people a lot of good and this report is absolutely not about taking treatment or services away from people where they are effective. But medicines can also cause harm and can be wasted." Read full story Source: BBC News, 22 September 2021- Posted
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Content ArticleThe government commissioned Dr Keith Ridge, Chief Pharmaceutical Officer for England, to lead a review into the use of medication and overprescribing.
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EventuntilThis online event is an important update for prescribers, and for those who take prescribed medicines, on the RPS Prescribing Competency Framework. This framework was originally produced in by the National Prescribing Centre as a competency framework for all prescribers, and updated by the Royal Pharmaceutical Society (RPS) in 2016. Join this event to: Hear about the changes to the RPS competency framework for all prescribers. Hear how others in pharmacy and other healthcare professions are using the framework. Ask questions to colleagues who were involved in updating the framework. Register
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Content ArticleThe rise in opioid overdoses warrants a review of the symptoms of akathisia writes Russell Copelan.
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Content ArticleIn this article in the Pharmaceutical Journal, Carolyn Wickware asks if liquid morphine should be reclassified. She cites research that Oramorph or oral morphine sulphate solution was directly linked to the cause of death in 13 reports since 2013.
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Content ArticleA National Patient Safety Alert has been issued on the elimination of bottles of liquefied phenol 80%. The alert has been issued by the NHS England and NHS Improvement National Patient Safety Team, British Orthopaedic Society, The Association of Coloproctology Great Britain and Ireland, and Royal College of Podiatry.
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Content ArticleStopping antidepressants commonly causes withdrawal symptoms, which can be severe and long-lasting. This paper, published in Therapeutic Advances in Psychopharmacology, outlines the themes emerging from 158 respondents to an open invitation to describe the experience of prescribed psychotropic medication withdrawal for petitions sent to British parliaments.
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Event
ePrescribing Masterclass
Sam posted an event in Community Calendar
untilJoin this one-hour session,with Bola Ruddock, Senior Project Manager in the Blueprinting Team at NHSx, to give an introduction to Blueprints. Jocelyn Palmer, Assistant Director of Programmes, NHSx will present on the 'What Good Looks Like' programme. What Good Looks Like (WGLL) is an NHSX led programme that aims to empower frontline leaders, so a CEO can see whether their organisation is doing everything it can to create a common vision for good digital practice across health and care. The ePrescribing masterclass series consists of a monthly webinar where NHS organisations can share their learning and experiences on digital transformation and enabling Trusts to follow in their footsteps as quickly and effectively as possible. The sessions are designed to accelerate digital transformation, reduce unwarranted variation, and deliver quality improvements in patient safety, clinical outcomes, and service user experience. It is also an opportunity for people to present at a national level. Register- Posted
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Content ArticleThe aim of this study from Avery et al. was to determine the prevalence and nature of prescribing errors in general practice; to explore the causes, and to identify defences against error. The study involved examination of 6,048 unique prescription items for 1,777 patients. Prescribing or monitoring errors were detected for 1 in 8 patients, involving around 1 in 20 of all prescription items. The vast majority of the errors were of mild to moderate severity, with 1 in 550 items being associated with a severe error. The following factors were associated with increased risk of prescribing or monitoring errors: male gender, age less than 15 years or greater than 64 years, number of unique medication items prescribed, and being prescribed preparations in the following therapeutic areas: cardiovascular, infections, malignant disease and immunosuppression, musculoskeletal, eye, ENT and skin. Prescribing or monitoring errors were not associated with the grade of GP or whether prescriptions were issued as acute or repeat items. A wide range of underlying causes of error were identified relating to the prescriber, patient, the team, the working environment, the task, the computer system and the primary/secondary care interface. Many defences against error were also identified, including strategies employed by individual prescribers and primary care teams, and making best use of health information technology.
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TEARDEW (COMPILED).png
Patient Safety Learning posted a gallery image in Medication
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Content ArticleThe Patient Safety Authority are inviting PharmD students and faculty to submit their manuscripts by 30 June. A panel of guest editors—pharmacy experts from across the United States—will select their favourites.
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Content Article
Inappropriate prescribing during a pandemic: dementia and antipsychotics
Anonymous posted an article in Dementia
Back in February, the team at Patient Safety Learning highlighted how the number of antipsychotic medication prescriptions for people living with dementia had increased in care settings. What’s worrying, is these prescriptions can be administered inappropriately and cause tremendous harm. This is one family's pandemic story. -
News Article
Patients harmed after roll-out of new IT system
Patient Safety Learning posted a news article in News
Patients have come to avoidable harm after a large private provider failed to deliver thousands of medicine prescriptions, according to a report from the Care Quality Commission. Healthcare at Home, which is based in Staffordshire but provides NHS-funded care and medicine supplies to patients’ homes across the country, has been rated “inadequate” and placed in special measures. A report published today said inspectors found more than 10,000 patients missed a dose of their medicine between October and December 2020 due to problems caused by the introduction of a new information system. Reviews have found some suffered avoidable harm as a result. Read full story (paywalled) Source: HSJ, 13 May 2021 -
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Learning from COVID-19 medical errors.jpg
Patient Safety Learning posted a gallery image in Medication
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Content ArticleStudents learn about medication and non-medication strategies for reducing symptoms of depression and other neuropsychiatric symptoms (e.g. agitation, anxiety) in people with dementia. While non-medication strategies are often emphasised as being preferable, often we lack the time and resources to facilitate their implementation. There is also a sense that people believe that medications worked better—even though we don’t really know if this is true since studies comparing medication to non-medication strategies are rare. The problem with prescribing medications in this patient population is that medications are associated with potentially catastrophic side effects (e.g. falls and fractures). Jennifer Watt and Zahra Goodarzi undertook a research project looking at the comparative efficacy of interventions for reducing symptoms of depression in people with dementia. Based on their clinical experience as geriatricians, they hypothesised that non-medication strategies could effectively reduce symptoms of depression because they are addressing its underlying causes.
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Content ArticleDr Helen Simpson, Lisa Shepherd and Dr Steve Kell summarise the guidance and implementation of the steroid emergency card in primary care.
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Content ArticleThe Medicines and Medical Devices Bill has received royal assent and has become law. The new Act will enable the Department of Health and Social Care (DHSC) to implement a number of policies to amend the existing regulatory frameworks, although generally regulations under the Act must first be introduced. The potential changes include: Supporting the availability of medicines: enabling hub and spoke arrangements between different legal entities, to ‘support wider use of automation to bring increased efficiencies’; requiring manufacturers to provide electronic patient information leaflets; and increasing the professions able to prescribe and supply certain medicines. Protecting the public: developing a UK medicines verification system; introducing a national registration scheme for online sellers of medicines; and facilitating supply of medicines and medical devices during non-pandemic public health emergencies.
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Content ArticleThe cornerstone of good general practice has long been recognised as lying in the quality of the relationship between doctor and patient. This focus on the interaction between GP and patient has been further reinforced in recent years by increasing attention on the patient’s experience of healthcare encounters. However, pleasing the patient is not always consistent with providing good-quality care. GPs are well aware that patients may demand an antibiotic when it is not judged clinically appropriate. The aim of this study from Ashworth et al. was to determine the relationship between antibiotic prescribing in general practice and reported patient satisfaction. The results found that patients were less satisfied in practices with frugal antibiotic prescribing. A cautious approach to antibiotic prescribing may require a trade-off in terms of patient satisfaction.
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EventThis conference focuses on reducing medication errors and resulting harm in line with the WHO Medication without Harm Programme goal to reduce the level of severe, avoidable harm related to medications by 50% over the next five years. The conference focuses on prioritising high risk medications and high risk patient groups to enable your interventions to have the highest impact on patient care and reduction in patient harm. The conference which aims to bring together clinicians and pharmacists, managers, and medication safety officers and leads will reflect on medication safety issues that have arisen as a result of the COVID-19 pandemic, understand current national developments, and to debate and discuss key issues and areas they are facing in improving and monitoring medication safety, and reducing medication errors and harm in hospitals. There will also be a focus on prescribing error following the recent HSIB investigation and the January 2021 investigation into prescribing error in children. Further information and registration or email: kerry@hc-uk.org.uk hub members receive 10% discount. Email: info@pslhub.org Follow the conversation on Twitter #MedicationErrors
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Content ArticleIn this blog, Steve Turner, a qualified nurse, specialising in clinical educational and patient engagement, offers up four tips for managing medicines in care home settings, under the following headings: Care Homes must have a medicines policy that is regularly reviewed. People must have an accurate listing of their medicines on the day they transfer to the care home. People who live in care homes should have at least 1 multidisciplinary medication review per year. Ensure you have safe systems for administering and recording medicines. To read the full blog and to find out more about each tip, follow the link below.
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Content ArticleEmerging evidence indicates that there has been an increase in the prescription of antipsychotic medications for people living with dementia in care settings during the COVID-19 pandemic. In this blog, Patient Safety Learning explores the patient safety concerns relating to the use of antipsychotic medications for people with dementia and suggests areas for further investigation and action.
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Content ArticleThe General Medical Council (GMC) has updated their ethical guidance on Good practice in prescribing and managing medicines and devices.
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Content Article
Top medication errors reported to ISMP in 2020
Anonymous posted an article in Coronavirus (COVID-19)
One of the most important ways to prevent medication errors is to learn from errors that have occurred in professional practice and to use that information to identify potential risk points or practices to prevent similar errors. This presentation from the Institute of Safe Medicines Practices (ISMP), looks at the top medication errors reported in 2020. -
Content ArticleHealth information technology (HIT) provides many benefits, but also facilitates certain types of errors, such as wrong-patient errors in which one patient is mistaken for another. These errors can have serious patient safety consequences and there has been significant effort to mitigate the risk of these errors through national patient safety goals, in-depth research, and the development of safety toolkits. Nonetheless, these errors persist.
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