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Found 323 results
  1. News Article
    LloydsPharmacy 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
  2. News Article
    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
  3. News Article
    Two people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal. Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage. At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died. City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed. An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world." “As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.” Read full story Source: Chronicle Live, 22 December 2019
  4. News Article
    Stakeholders from across various sectors in Australia attended a medicine safety forum convened in Canberra on Monday. Held by the Consumers Health Forum of Australia (CHF), Pharmaceutical Society of Australia (PSA), the Society of Hospital Pharmacists of Australia (SHPA), NPS MedicineWise and academic partners Monash University and University of Sydney, the forum challenged participants to ‘think differently’ on the safe use of medicines in Australia. This included brainstorming on what success in improving medicine safety would look like in 10 years. “Medicine safety is a priority for us all and we each have a role to play,” PSA National President Associate Professor Chris Freeman said. “It was inspiring to see the sector work together today to proactively identify those measures we can cooperatively pursue to make a real difference and protect patients.” Read full story Source: AJP.com.au
  5. News Article
    More deaths could occur unless action is taken to keep people safe when obtaining medications from online health providers, says a UK coroner. Nigel Parsley has written to Health Secretary Matt Hancock highlighting the case of a woman who died after obtaining opiate painkillers online. Debbie Headspeath, 41, got the medication, dispensed by UK pharmacies, after website consultations. Her own GP was unaware of what she had requested from doctors on the internet. The Suffolk coroner has now written to the Department of Health asking for urgent action to be taken. The General Pharmaceutical Council – the independent regulator for pharmacies – said it was responding to the coroner's report and would continue to take necessary action to make sure medicines are always supplied safely online. Read full story Source: BBC News, 9 December 2019
  6. News Article
    Greater Manchester community pharmacies have signed up to a new national scheme, which will see patient consultations booked via NHS 111 for the very first time. The scheme launched on the 29 October is part of major plans to boost the role of pharmacists in patient care, outlined in the national NHS Long Term Plan. People who call the free NHS 111 phone service can now be offered same day consultation with their local community pharmacist, if they need an urgent supply of a prescription medicine or advice on minor illnesses. The aim of the scheme is to leverage pressure on GP practices and A&E departments, which come under increasing strain when the winter hits. Early stages of the initiative in other parts of the country found that an estimated 6% of all GP consultations could be handled by a community pharmacist, freeing up around 20 million GP appointments each year nationally. Sarah Price, Executive Lead for Population Health and Commissioning at Greater Manchester Health and Social Care Partnership said: “Our health services are facing unprecedented challenges and that means finding new ways to deliver the standard of care that patients expect, whilst ensuring that services are sustainable and fit for the future. Doing things the way we’ve always done, is no longer an option. Greater Manchester pharmacists are rising to the challenge and becoming more closely involved in patient care, often in close partnership with other health and care professionals." Read full story Source: National Health Executive, 4 December 2019
  7. News Article
    More than 2.8 million antibiotic-resistant infections occur in the U.S. every year, and more than 35,000 people die as a result of those infections, according to a newly released Centers for Disease Control and Prevention (CDC) report. The updated Antibiotic Resistance Threats in the United States (AR Threats Report) also estimates when antibiotic-resistant bacterium Clostridium difficile (or C. diff) is included, that number exceeds 3 million infections and 48,000 deaths. The report, which used data sources such as electronic health records not previously available, shows that there were nearly twice as many annual deaths from antibiotic-resistant infections as the CDC originally reported in 2013. CDC officials called the numbers in this report "more precise, though still conservative, estimates of the human costs of antibiotic resistance. Read full story Source: FierceHealthcare, 13 November 2019
  8. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
  9. Content Article
    In 2016, the Centers for Disease Control and Prevention published prescribing guidelines for opioids. Though intended to encourage best practices in opioid prescribing, these guidelines fueled providers’ fears of opioids and led to many clinicians abandoning patients who relied on opioids for pain relief. In this article, Antje M. Barreveld reflects on the harms he may have caused by underprescribing these drugs, not overprescribing them.
  10. Content Article
    Children born to women who take valproate during pregnancy are at significant risk of birth defects and persistent developmental disorders. As such, it is vital that women and girls are dispensed valproate safely. The General Pharmaceutical Council is reminding all pharmacy professionals of what they must do to ensure women and girls receive the right information about valproate and the risk of birth defects. The update includes
  11. Content Article
    This guidance from the British Medical Association (BMA) covers frequently asked questions around prescribing in primary care and informs GPs of the BMA general practice committee’s policies in prescribing.
  12. Content Article
    Medication errors are any Patient Safety Incidents (PSI) where there has been an error in the process of prescribing, preparing, dispensing, administering and monitoring or providing advice on medicines.  From 1 April 2015 until 31 March 2020 NHS Resolution received 1420 claims relating to medication errors.  This leaflet from NHS Resolution analyses closed claims that have been settled with damages paid and concern an element of the medication process: prescribing, transcribing, dispensing, administering and monitoring. 
  13. Content Article
    For many people, improving their health and wellbeing requires a holistic approach and support by professionals who can help them focus on what matters to them to live well. Social prescribing supports people to understand their needs and connects them to local community (non-clinical) often voluntary services which can provide the help they need.
  14. Content Article
    This article in the journal Archives of Disease in Childhood examines patient safety theories and suggests principles to tackle safety challenges specific to paediatric care. The authors provide an overview of the evolution of patient safety theories and tools such as huddles and electronic prescribing. They look at the example of Paediatric Early Warning Systems (PEWS), highlighting that the organisational context and culture in which PEWS is used will dramatically affect its effectiveness as a tool. They conclude that approaches to patient safety must see it as a complex interconnected whole, rooted in the culture and environment in which safety interventions act. They also argue that paediatricians must take a lead in improving the safety of the care they deliver on a systems basis.
  15. Content Article
    Potassium permanganate is routinely used in the NHS as a dilute solution to treat weeping and blistering skin conditions, such as acute  weeping/infected eczema and leg ulcers. It is not licensed as a medicine. Supplied in concentrated forms, either as a ‘tablet’ or a solution, it  requires dilution before it is used as a soak or in the bath. These concentrated forms resemble an oral tablet or juice drink and if ingested are highly toxic; causing rapid swelling and bleeding of the lips and tongue, gross oropharyngeal oedema, local tissue necrosis, stridor, and gastrointestinal ulceration. Ingestion can be fatal due to gastrointestinal haemorrhage, acute respiratory distress syndrome and/or multiorgan failure. Even dilute solutions can be toxic if swallowed. A Patient Safety Alert issued in 20142 highlighted incidents where patients had inadvertently ingested the concentrated form, and the risks in relation to terminology and presenting tablets or solution in receptacles that imply they are for oral ingestion, such as plastic cups or jugs. A review of the National Reporting and Learning System over a two-year period identified that incidents of ingestion are still occurring. One  report described an older patient dying from aspiration pneumonia and extensive laryngeal swelling after ingesting potassium permanganate tablets left by her bedside. Review of the other 34 incidents identified key themes: healthcare staff administering potassium permanganate orally patients taking potassium permanganate orally at home, or when left on a bedside locker potassium permanganate incorrectly prescribed as oral medication. The British Association of Dermatologists (BAD) ‘Recommendations to minimise risk of harm from potassium permanganate soaks’ includes advice on formulary management, prescribing, dispensing, storage, preparation and use, and waste.
  16. Content Article
    This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Roohil talks to us about the vital role of pharmacists in making sure medications help patients, rather than causing harm. She highlights the global threat of substandard and counterfeit medicines, the need to improve access to medicines and the importance of having pharmacists 'on the ground' to help patients understand how to take them.
  17. Content Article
    The 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.
  18. Content Article
    This article in the British Journal of Clinical Pharmacology aimed to calculate the medication costs of potentially inappropriate prescribing for middle-aged adults compare with the cost of consensus-validated, evidence-based, ‘adequate’ alternative prescribing scenarios. It used a Delphi consensus panel and cross-sectional study to examine primary care data of 55,880 patients aged 45-64 years old in South London. The study found that duplicate drug classes was the most costly criterion for both PIP and alternative prescribing. It identified no substantial cost difference between adequate prescribing versus PIP and the authors recommend that future studies investigate the wider health economic costs of alternative prescribing, such as reducing hospital admissions.
  19. Content Article
    Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. The World Health Organization (WHO) has launched the Third WHO Global Patient Safety Challenge: Medication Without Harm to improve medication safety. Considering the huge burden of medication-related harm, Medication Safety has also been selected as theme for World Patient Safety Day 2022. WHO is launching a series of webinars to introduce the strategic framework for implementation of the Challenge, technical strategies, tools and provide technical support to countries for reducing medication-related harm. The webinars will share country and patient experiences in implementing the Challenge. These presentations from the opening webinar sets out the urgency to address the challenge, the strategic framework and progress to date. 
  20. Content Article
    Where a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
  21. Content Article
    There are many respects in which the modern medical system is not fit for purpose and poses a threat to human health. In so many situations, our superficial assumptions about medicine are wrong. Having more tests to identify disease is often not better than leaving those “well enough” alone, labelling people with a specific disease may not be helpful, and more medicine may not be better than less medicine or no medicine at all. In our eagerness to intervene, we can end up doing harm. This fits with the estimation that around 30% of medical care is ineffective and another 10% is harmful. But why do doctors recommend tests, or diagnose and prescribe treatments that don’t help people? Ian A Harris, an orthopaedic surgeon, and Rachelle Buchbinder, a professor of clinical epidemiology, discuss in this BMJ opinion article.
  22. Content Article
    This e-book provides an extensive overview of the day-to-day challenges posed by antimicrobial resistance, tools for setting up stewardship programmes and guidance of how to make the most of existing programmes. Its resources apply the principles of antimicrobial stewardship to a wide range of professions, populations and clinical/care settings. It was published by the British Society for Antimicrobial Chemotherapy in collaboration with the European Society of Clinical Microbiology and Infectious Diseases.
  23. Content Article
    Antibiotic resistance is a natural phenomenon that happens when bacteria develop the ability to defeat the drugs designed to kill them. This case study focuses on large outbreaks of antibiotic-resistant strains of cholera and typhoid in Zimbabwe. It describes the steps taken to tackle the outbreaks, including a mass typhoid Vi-conjugate vaccine (TCV) vaccination campaign from February to March 2019 in nine suburbs of Harare that were severely affected by the outbreak.
  24. Content Article
    World Antimicrobial Awareness Week takes place from the 18-24 November every year. On this page the WHO explains what antimicrobial resistance is and provides several short explanatory videos about how this can be prevented.
  25. Content Article
    This study in the British Journal of Clinical Pharmacology involved searching electronic health records to uncover how many people in prisons have been affected by a potential problem related to their prescribed medication. Researchers looked at published studies and worked with prison healthcare staff to develop and implement prescribing safety indicators (PSIs) for prison electronic health records. The authors found that PSIs provide a significant opportunity to measure and improve medication safety for people in prisons and that more patients were affected by some PSIs than others. The study also investigated how the searches could be used more widely in prisons and interviewed 20 prison health care staff to explore this topic. The staff they spoke to said that it was important to have people who can take on leadership of the searches and to promote team-based responses to them.
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