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News Article
Cost of living: GPs warning over rise in prescription requests
Patient Safety Learning posted a news article in News
The cost of living crisis is adding to pressures on GPs, the British Medical Association (BMA) in Northern Ireland has warned. The BMA said that is because the number of people asking for prescriptions for medicines that can be bought over the counter is increasing. That includes medicines like painkillers and allergy medication, Dr Alan Stout of the BMA said. Prescriptions are free for everyone in Northern Ireland. The rise in prescription request increases "the cost to the health service as a whole and the pressure on GPs", Dr Stout told Ulster's Good Morning Ulster programme. "We have talked before about the difficulties people have accessing GPs and this is just more demand and difficulties," he said. Dr Stout added: "I absolutely don't hold that against anyone, it is not our position as GPs to deny people medication or deny people prescriptions if they need this medication." Read full story Source: BBC News, 23 June 2022 -
News Article
Time for change: The College of Medicine launches its Beyond Pills campaign
Patient Safety Learning posted a news article in News
On Thursday 16 June, The College of Medicine launched its Beyond Pills campaign – calling for Government intervention on over-prescribing – at the Integrated and Personalised Medicine Congress 2022. Around 1.1 billion medicines are currently prescribed unnecessarily. Supported by eminent voices in both the Government and our healthcare system, the Beyond Pills campaign calls for the Government to immediately address the nation’s unsustainable prescription service through re-prescribing and social prescribing. Speaking at the Integrative and Personalised Medicine Congress 2022, The College of Medicine Chair Dr Michael Dixon said: “Medicine, as we know it, is no longer affordable or sustainable. Nor is it able to curb the increase in obesity, mental health problems and most long-term diseases. “A new medical mindset is needed, which goes to the heart of true health care. The advantages and possibilities of social prescription are limitless. “An adjustment to the system now will provide a long-term, sustainable solution for the NHS to meet the ever-increasing demand for funding and healthcare professionals.” The Campaign was established in the wake of the Chief Pharmaceutical Officer’s National Overprescribing Review published in September 2021. The Beyond Pills Campaign aims to reduce drug prescription, expand the number of social prescribing link workers, save crucial funds, and provide support to individuals and local communities hampered by health inequalities. To achieve these goals, it has today launched a campaign that includes six specific actions that need to be taken: Improving medical and healthcare training. Social prescribing and a psychosocial approach to treatment needs to be embedded throughout the curriculum Addressing financial incentives within the NHS. Financial incentives in the system should centre around community health. For those patients already on a cocktail of pills, medication reviews and appropriate deprescribing need to be emphasised Increasing the number of social prescribing link workers. Primary Care Networks need to employ more link workers to enable access to social prescribing for everyone who could benefit Increasing support for the voluntary sector. Government departments need to fund and support voluntary initiatives that encourage healthy communities Empowering individuals and communities. Informing individuals about social prescribing and collaborating with volunteers involved in social prescription and local health creation and showcasing benefits Further systematic research. Mobilising the research community to develop a fully-fledged programme review into topics including the therapeutic efficacy of social prescribing Read full story Source: College of Medicine, 16 June 2022 -
News Article
Bristol NHS 'causing harm' to patients by withholding thyroid drug
Patient Safety Learning posted a news article in News
Bristol's NHS commissioning group is one of many across the country which is "causing harm" to people with thyroid problems by limiting the provision of a drug, a new report says. Analysis from the Thyroid Trust says that 58 per cent of NHS Clinical Commissioning Groups in England are withdrawing, refusing or reducing prescriptions of T3 for people with underactive thyroids - against national guidance. People who have thyroid problems can suffer from depression, crippling fatigue, weight gain and muscle weakness, which can be alleviated by the drug. But the Bristol, North Somerset and South Gloucestershire CCG does not permit prescribing the drug for new patients, according to the report. One Westcountry woman told the Express that she had her T3 prescription withdrawn, which caused her significant problems. Former police officer Carole Morgan-Anstee, 62, told the website she went through "hell" after her T3 was stopped. The Somerset woman was prescribed the drug after suffering symptoms including chronic fatigue and hair loss for 15 years. But after being treated with T3 for five years, her endocrinologist told her he had been ordered to stop prescribing it for her. He reportedly said the problem was that her local Bristol North Somerset and South Gloucestershire CCG had began cutting back on T3 supplies. Carole said: "I was really upset. It was hell. My treatment was completely within the guidelines and he knew how ill I would get if they took it away. The Thyroid Trust report says: "Around the country most Clinical Commissioning Groups have policies in place which are causing harm to patients by denying treatment. In those cases where this has occurred, patients have resorted to the private sector or to informal means, such as buying the medication online, or even travelling abroad where it is sometimes available to buy over the counter, to source the medicine they need which the NHS should be providing. Read full story Source: Bristol Post, 15 June 2022 -
News Article
Inadequate Reading surgery had 'backlogs of test results', CQC says
Patient Safety Learning posted a news article in News
A GP surgery that provides treatment to about 5,600 patients has been placed in special measures by a regulator. London Street Surgery, in Reading, Berkshire, was found to have "significant backlogs of test results and care-related tasks". The Care Quality Commission (CQC) found there was "poor identification of risks to patients" during an inspection in April. The surgery has been approached for comment. The regulator rated the surgery's safety and leadership as inadequate, and said it had insufficient processes to ensure services' safety and effectiveness. Repeat prescriptions and medicines were "not managed safely", which could have posed risks to patients, and there were "risks associated" with the storage of blank prescriptions, it found. Staff training was "not monitored appropriately" and inspectors found patients with learning disabilities were not provided with health checks to make sure their wellbeing was properly monitored. Read full story Source: BBC News, 7 June 2022 -
News ArticleA cross-border trial has improved care for patients prescribed multiple medicines. The iSIMPATHY project, funded by the European Union's INTERREG VA Programme, worked with professionals in Scotland, the Republic of Ireland and Northern Ireland to comprehensively review patient medication. Taking multiple medicines can be problematic if the increased risk of harm from interactions between drugs, or between drugs and diseases, outweighs the intended benefits. Interim findings showed these interventions potentially prevented major organ failure, adverse drug reactions, avoided hospital admissions and saw patients moved to more appropriate medication. Scotland’s Public Health Minister Maree Todd said: “This project looked at some of our most vulnerable patients taking more than five medications. The reviews have avoided adverse combinations of drugs and hospitalisations while also reducing prescriptions and drugs costs. “We will know more when the full evaluation is published in June, we will work with partners to see how we can these improvements can be applied more widely, potentially saving lives and money.” Read full story Source: Scottish Government, 10 March 2023
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News Article
Prescribing antidepressants for chronic pain lacks evidence, experts say
Patient Safety Learning posted a news article in News
Researchers have warned there is a lack of evidence around prescribing antidepressants for chronic pain. Guidance from the National Institute for Health and Care Excellence (Nice) in 2021 recommends that an antidepressant (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) can be considered for people aged 18 and over with pain lasting longer than three months which cannot be accounted for by another diagnosis. The guidance said the drugs may help with quality of life, pain, sleep and psychological distress, even if the patient is not suffering depression. A separate guideline on neuropathic (nerve) pain recommends offering a choice of treatments, including amitriptyline and duloxetine, alongside a discussion on possible benefits and side-effects. However, researchers writing in the BMJ have warned that recommending antidepressants for pain is not always backed by evidence. Professor Martin Underwood from the University of Warwick, said: “There is a role for antidepressants in helping people living with chronic pain, however, this is more limited than previously thought. “Antidepressants may have unpleasant side effects that patients may wish to avoid. “We need to work harder to help people manage their pain and live better, without relying on the prescription pad.” Read full story Source: The Independent, 1 February 2023 -
News Article
Older patients on medley of drugs ‘at higher risk of adverse reactions’
Patient Safety Learning posted a news article in News
Older women are at higher risk than older men of experiencing adverse reactions to drugs prescribed by their family doctor, and older patients taking more than 10 medicines are at higher risk than those taking fewer, according to a study. Overall, one in four older people experience adverse drug reactions (ADRs) to pills prescribed by their GP, the research published in the British Journal of General Practice suggests. It has prompted calls for GPs to consider deprescribing ineffective medications and prioritise patients taking lots of drugs for a regular review of their prescriptions. The medicines most commonly associated with ADRs included those used to treat high blood pressure and other cardiac conditions, strong painkillers such as tramadol, and antibiotics such as amoxicillin, according to the study. The study monitored 592 patients aged 70 and older across 15 general practices in the Republic of Ireland over a six-year period. One in four experienced at least one ADR. Patients prescribed 10 or more medicines had a threefold increased risk of experiencing a reaction, researchers said. Women were at least 50% more likely to have ADRs than men, the study found. “ADRs can be difficult to identify in medically complex older adults as they often present as non-specific symptoms,” the researchers wrote in the British Journal of General Practice. “GPs are well placed to detect the occurrence of ADRs from drugs prescribed in primary care as well as in other care settings. Deprescribing of ineffective medications and those no longer clinically indicated is one approach to reducing the risk of ADRs in older patients.” Read full story Source: The Guardian, 24 January 2023 -
News ArticleHigh risks relating to the ordering, prescribing, storing and administration of medicines have been found by the Mental Health Commission in a series of inspections of mental health centres in Dublin. The commission emphasised the need to have appropriate practices including the recording of the minimum dose interval information; where medication has been stopped, the stop date to be recorded; and the need to always have the prescriber’s signature recorded. The inspector of mental health services Dr Susan Finnerty said it was positive to see centres maintaining high compliance rating, but spoke of concerns around the administration of medication. “We know that medication is an important tool in treatment of mental illness. In order to reduce the risk of medication errors, we need to be sure that medication prescription and administration records are completed correctly,” Dr Finnerty said. Read full story Source: Independent Ireland, 18 January 2023
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News Article
Antidepressants ‘should be reduced in stages’ to avoid withdrawal symptoms
Patient Safety Learning posted a news article in News
GPs whose patients want to stop taking antidepressants should reduce the dose of their medication in stages to lower the risk and severity of withdrawal symptoms, the medicines watchdog has said. About one in six (16%) adult Britons experience moderate to severe depression, according to the Office for National Statistics. In England alone, 21.4m antidepressant drugs were prescribed between July and September 2022, according to the NHS Business Services Authority. A new draft quality standard for the care of adults with depression from the National Institute for Health and Care Excellence (NICE) – the first update in 11 years – includes specific guidance to help adults come off antidepressant medication permanently. NICE’s independent advisory committee, which includes experts in treating adults with depression, recommends the staged withdrawal of antidepressants in patients who want to stop taking the drugs. A staggered reduction of medicine, known as tapering, helps to reduce withdrawal effects and long-term dependence on the medication, according to Nice. The committee said primary care and mental health professionals should follow the NICE guideline recommendations on stopping antidepressant medication, including agreeing with their patient whether it is right for them to stop taking the medication and, if so, the speed and duration of withdrawal from it. Read full story Source: The Guardian, 17 January 2023 -
News Article
Private menopause clinics prescribing HRT at 'twice the recommended dose'
Patient Safety Learning posted a news article in News
Private menopause clinics are prescribing HRT at "twice the recommended dose", an investigation has revealed. The investigation by The Pharmaceutical Journal has revealed that patients attending private menopause clinics are subject to “unorthodox prescribing” by providers. Many are receiving oestrogen at up to double the recommended dose placing them at higher risk of cancer and vaginal bleeding. Nuttan Tanna, a pharmacist consultant in women’s health at London North West University Healthcare NHS Trust, said she had seen referrals for “bleeding investigations” and then found the patient was on "very large doses [of oestrogen] prescribed previously by private providers”. Brendon Jiang, a senior clinical pharmacist for North Oxfordshire Rural Alliance Primary Care Network, said that his team were increasingly getting letters from private clinics requesting for patients to be prescribed doses of oestrogen that are off-label or exceed licensed recommendations. He also raised concerns that patients were not taking enough progesterone alongside increased doses of oestrogen. Taking increased doses of oestrogen alone can increase the risk of womb cancer but progesterone protects against that risk and therefore the two hormones should be taken together. Read full story (paywalled) Source: The Telegraph, 19 December 2022 Further reading on the hub: Surgical menopause: a toolkit for healthcare professionals (British Menopause Society) Menopause Support - Getting the most out of your doctor’s appointment World Menopause Day 2022: Raising awareness of surgical menopause All-Party Parliamentary Group on Menopause: Inquiry to assess the impacts of menopause and the case for policy reform - conclusions -
News ArticleMedicine shortages are an “increasing problem” for Australia and antibiotics are among the commonly prescribed drugs currently in short supply, the peak body for general practitioners says. The drugs regulator, the Therapeutic Goods Administration (TGA), said the three most commonly prescribed antibiotics – amoxicillin, cefalexin and metronidazole – are scarce. They are used to treat a range of bacterial infections, including pneumonia and other chest infections, skin infections and urinary tract infections. To see patients through the shortage, the TGA has authorised pharmacists to provide alternative antibiotics without approval from the prescribing doctor. “Importantly, many of these medicines have alternatives available,” the TGA said. “Your pharmacist may be able to give you a different brand, or your doctor can prescribe a different strength or medicine with similar spectrum of activity.” A TGA spokesperson said “most of the antibiotic shortages are caused by manufacturing issues or an unexpected increase in demand”. Dr Nicole Higgins, the president of the Royal Australian College of General Practitioners, said the shortage of certain medicines was “becoming an increasing problem in Australia”. Read full story Source: The Guardian, 12 December 2022
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News Article
Ministers failing to reform ‘restrictive’ primary care rules
Patient Safety Learning posted a news article in News
The government has failed to change ‘restrictive’ legislation which would enable primary care reform – despite repeated announcements – a pharmacy leader has said. Currently, pharmacy technicians cannot take on dispensing tasks without supervision from a pharmacist but the government promised in 2019 to look at how legislation can be updated to allow pharmacy technicians to take more of a role in dispensing, as part of the current five-year Community Pharmacy Contractual Framework, which ends next year. The government has repeatedly announced and reannounced over the past five years that it wants to remove restrictions to give community pharmacy an expanded role. But in a new report shared exclusively with HSJ, the Company Chemists’ Association – the trade body with members including Asda, Boots, Lloyds Pharmacy and Superdrug – highlights that government has failed to make progress. Read full story (paywalled) Source: HSJ, 7 June 2023 -
News Article
Plan for GPs to offer NHS patients weight-loss jab
Patient Safety Learning posted a news article in News
GPs in England may start offering weight-loss jabs to some patients to reduce obesity-related illnesses and resultant pressure on hospitals. Wegovy was approved for NHS use after research suggested users could shed over 10% of their body weight. The drug blunts appetite, so users feel full and eat less. Rishi Sunak said it could be a "game-changer" as he announced a £40 million pilot scheme to increase access to specialist weight management services. But experts warn "skinny jabs" - widely used in the US and endorsed by many celebrities - are not a quick fix or a substitute for a healthy diet and exercise. NHS drugs watchdog, the National Institute for Health and Care Excellence (NICE), says patients can access Wegovy for a maximum of two years via specialist weight-management services. The new scheme will test how GPs could safely prescribe such drugs and the NHS provide support in the community or digitally, contributing to the government's wider ambition to reduce pressure on hospitals and give patients access to the care they need where it is most convenient for them. Read full story Source: BBC News, 7 June 2023 -
News Article
FDA proposes revamping medication guides that come with prescriptions
Patient Safety Learning posted a news article in News
The US Food and Drug Administration has proposed to add to what you get with your prescription drugs. The proposed rule would require the prescriptions you get to come with a new kind of single-page medication guide with an easy-to-use set of directions and easy-to-understand safety information, a goal the FDA has been working toward for years. One study found that nearly 75% of Americans have had trouble taking their medicine as directed. A lot of that is due to cost – people might not be able to afford their medicine, so they don’t take it – but some is due to confusion. They might get more than one kind of written information with their prescription, or the information they receive can be conflicting, incomplete or repetitive, the FDA said. When people are confused or misinformed about their prescription, there is a good chance they will not take it or will stop taking it, and that can directly hurt their health. “Research suggests that medication nonadherence can contribute to nearly 25% of hospital admissions, 50% of treatment failures, and approximately 125,000 deaths in our country each year,” the FDA says. The agency said the new proposal is also meant to help fight the “nation’s crisis with health care misinformation and disinformation.” Read full story Source: CNN, 30 May 2023 -
News ArticleA brand-new genetic research resource, known as a ‘biobank’, will be piloted by the Medicines and Healthcare products Regulatory Agency (MHRA) in a joint venture with Genomics England to better understand how a patient’s genetic makeup can impact the safety of their medicines. The Yellow Card biobank, which will contain genetic data and patient samples, will operate alongside the MHRA’s Yellow Card reporting site for suspected side effects and adverse incidents involving medicines and medical devices. It forms part of a long-term vision for more personalised medicine approaches, as scientists will use the repository of genetic information in the biobank to determine whether a side effect from a medicine was caused by a specific genetic trait. This will in turn enable doctors to target prescriptions using rapid screening tests, so patients across the UK will receive the safest medication for them, based on their genetic makeup. Adverse Drug Reactions (ADRs), or side effects, continue to be a significant burden on the NHS and account for one in 16 hospital admissions. Understanding the underlying mechanism of an adverse reaction would support the development of pharmacogenetic testing strategies, such as the screening tests enabled through the information provided by the Yellow Card biobank. These strategies would in turn provide the opportunity to prevent rather than react to adverse drug reactions. The biobank pilot will officially begin on 1 June 2023 with participant recruitment commencing later this year, on 1 September. Read full story Source: MHRA, 25 May 2023
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News Article
WHO issues warning on weight loss drug Wegovy
Patient Safety Learning posted a news article in News
New weight loss drugs such as Wegovy will not be a “silver bullet” in tackling obesity, the World Health Organization (WHO) has warned. Francesco Branca, WHO director of food and nutrition safety, said weight loss drugs must be used alongside a healthy diet and exercise. Ms Branca’s comments come as the health body conducts its first review of obesity management guidelines in two decades. Semaglutide, marketed as Wegovy by drugmaker Novo Nordisk, is an appetite suppressant drug that has been approved by the UK medicines regulator and described by some as a “game changer” in helping people to shed weight. People will only be given Wegovy on prescription as part of a specialist weight management service involving input from several professionals and for a maximum of two years. Some experts described the decision as a “pivotal moment” for the treatment of people living with obesity but others warned that the drug is not a “quick fix”. Read full story Source: The Independent, 12 May 2023 -
News ArticleStaff shortages forced pharmacies to shut for 100,000 hours in a year, new figures show, just as the government has unveiled plans to shift more GP work their way. The data, shared exclusively with The Independent by the organisation which represents pharmacies in England, also showed that almost 1,000 establishments closed for good between October 2016 and November 2022. The Pharmaceutical Services Negotiating Committee (PSNC) figures revealed that pharmacies in the most deprived areas were more likely to shut permanently due to lack of staff, with areas such as Birmingham and Manchester among the worst affected. The figures come as the government announced plans on Tuesday to allow pharmacists to prescribe medicines for conditions including earache, sore throats and urinary tract infections without GP involvement. However, experts have said the plans are unlikely to significantly reduce pressure on GP practices as prescriptions for these conditions make up just 3 per cent of all appointments. And the King’s Fund health think tank warned of the potential for a postcode lottery – saying some pharmacies will not be able to offer the services because they may not have access to diagnostic tools, or sufficient staff and consultation rooms. Read full story Source: The Independent, 10 May 2023
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News Article
Online UK pharmacies prescribing weight loss jabs to people with healthy BMI
Patient Safety Learning posted a news article in News
Online pharmacies operating in the UK are approving and dispatching prescriptions of controversial slimming jabs for people of a healthy weight, a Guardian investigation has found. Some pharmacies appear to be issuing prescriptions of such medications to people who lie about their body mass index (BMI) on an online form. In one case a reporter was issued a prescription after accurately saying their BMI was about 20. A healthy BMI lies between 18.5 and 24.9. The findings have raised alarm among eating disorder charities, which have warned that weight-loss medications should only be sold under the strictest conditions. Their concern has prompted calls for online pharmacies to employ stronger health checks and screening for eating disorders. Read full story Source: The Guardian, 10 May 2023 -
News ArticleMillions of patients in England will be able to get prescriptions for seven common conditions, plus more blood pressure checks and the contraceptive pill, directly from pharmacies under proposals to tackle the crisis in GP surgeries. Those suffering from earache, a sore throat, sinusitis, impetigo, shingles, infected insect bites and uncomplicated urinary tract infections (UTIs) in women are set to be prescribed medicine by pharmacists without the need to see a doctor or nurse for the first time. The reforms are designed to free up 15m GP appointments over the next two years. The blueprint was broadly welcomed by health leaders, with Thorrun Govind, chair of the Royal Pharmaceutical Society in England, calling it a “real game-changer” for patients. But experts said not all pharmacies would be able to offer all or any of the new services, meaning the shake-up could result in frustrated patients being “bumped from pillar to post, only to end up back at the GP”. There are also concerns that patients may not be able to recognise the seriousness of some conditions, including whether a UTI can be classed as “uncomplicated”. Read full story Source: The Guardian, 9 May 2023
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News Article
Mifepristone: US Supreme Court delays abortion pill access decision
Patient Safety Learning posted a news article in News
The US Supreme Court has extended until Friday a temporary block on limits to access of a popular abortion pill. A Texas judge suspended approval of abortion drug mifepristone on 7 April, questioning its safety. Parts of that decision were upheld on appeal, prompting the Biden administration to make an emergency request to the Supreme Court. It's the most significant such case since the Supreme Court last year ended the nationwide right to abortion. The pill - used in more than half of abortions in the US - was first approved by the Food and Drug Administration (FDA) more than two decades ago. Critics say that by overriding the FDA's approval, the court in Texas has usurped the federal health agency's remit to regulate food, medicine, and medical devices. Legal experts warn the ruling opens the door for challenges to other approved medicines in the US and could also stifle development of future drugs. Read full story Source: BBC News, 20 April 2023 -
Content ArticleChronic pain is common and debilitating, affecting about one in five people globally. However, chronic pain can be difficult to treat, and management is often suboptimal. The 2021 National Institute for Health and Care Excellence guideline for chronic primary pain explicitly recommends against the use of pain medicines, with the exception of antidepressants. To provide patients and clinicians with an updated and comprehensive resource on the efficacy, safety, and tolerability of antidepressants to treat pain, Ferreira et al. conducted an overview of relevant systematic reviews. The study found no review could provide high certainty evidence on the effectiveness of antidepressants for pain for any condition. Nine reviews did provide evidence that some antidepressants were effective, such as moderate evidence suggesting serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine, were effective for back pain, post-operative pain, fibromyalgia and nerve pain. However, the study only found low certainty evidence that selective serotonin reuptake inhibitors (SSRIs) were effective for people with depression and pain related to other conditions, and that tricyclic antidepressants (TCAs) were effective for irritable bowel syndrome, nerve pain and chronic tension-type headaches. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions.
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Content ArticleTo date, research on adverse drug reactions (ADRs) has focused on secondary care, and there is limited studies that have prospectively examined ADRs affecting older adults in general practice. This study from Doherty et al. examined the cumulative incidence and severity of ADRs and associated patient characteristics in a sample of community-dwelling older adults. They found that over one-quarter of older adults experienced an ADR over a 6-year period. Polypharmacy is independently associated with ADR risk in general practice and older adults on ≥10 drug classes should be prioritised for regular medication review.
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Content Article
Green Health Routes (NHS Forest, December 2022)
Patient_Safety_Learning posted an article in Social prescribing
Research shows that access to green space can support mental and physical health and wellbeing, and reduce the incidence of chronic conditions such as cardiovascular disease, type 2 diabetes and Alzheimer's. Green Health Routes can be used by GPs and other health professionals as part of social prescribing initiatives. Green Health Routes support communities to connect with and get to know the parks, meadows and woodlands on their doorsteps. The projects begin with the creation of neighbourhood maps, developed in close consultation with communities, to highlight the areas’ publicly accessible green space. -
Content ArticleThis webinar by the World Health Organization (WHO) is part of a series hosted to mark World Patient Safety Day 2022, which focused on the theme of 'Medication without harm'. This webinar looks at medication safety in polypharmacy, introducing the WHO technical report on Medication safety in polypharmacy. It features perspectives on medication management from patients, carers and national healthcare leaders.
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Content ArticleThe BMJ, in partnership with the Choosing Wisely international collaboration, led by the Choosing Wisely Canada campaign, has introduced a “Change” series in the Education section. Articles in the series highlight evidence based strategies and tools to help change practice and reduce unnecessary tests, treatments, and procedures. The articles indicate why and how practice needs to change, usually focusing on one aspect of care, and are aligned with recommendations made by national Choosing Wisely campaigns.
