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Found 143 results
  1. Content Article
    Download the report Parkinson's UK have also issued a joint statement with other charities whose patients are impacted by needing time-critical medication with the support from professional bodies. Further reading on the hub: Medication delays: A huge risk for inpatients with Parkinson’s Keeping patients with Parkinson’s safe in hospital: 4 key actions for staff
  2. News Article
    A mental health trust has been served with a warning notice ordering improvements in its processes around rapid tranquillisation of patients. The Care Quality Commission said the trust needed to ensure all staff at Kent and Medway NHS and Social Care Partnership Trust followed local and national recommendations to monitor and record a patient’s physical health when rapid tranquillisation was administered. Inspectors were concerned staff were not always aware of the potential impact of these medications. Serena Coleman, CQC deputy director of operations in the south, said: “We found some staff weren’t always using the least restrictive options to make sure that people’s behaviour wasn’t controlled by an excessive use of medicines. “As required medication, such as lorazepam and promethazine, was being used quite frequently but we couldn’t always find records to explain why these medications were necessary. There were examples where reviews hadn’t happened for long periods, meaning staff couldn’t be sure it was still appropriate to administer to people." Read full story (paywalled) Source: HSJ, 3 August 2023
  3. Content Article
    A study in 2018 found that 237 million medication errors occur each year in the NHS in England alone. Three quarters of these cause harm and there are 1,700–22,303 deaths from avoidable adverse drug reactions. Two things immediately strike me about these numbers: Medication safety is a huge issue. The breadth of the estimate suggests that data about the scale and impact of medication safety errors are incomplete and unreliable. I have not seen a similar published study since. My experience working with NHS hospitals since 2018 suggests slow progress. There are four reasons: The spaghetti medusa of data. Millions of staff hours spent to capture and store medicines data in a variety of legacy siloed hospital systems such as EPMA, pharmacy stock and EPR. The NHS employs 1.5 million people and at least the same number again work in social care. Yet there are almost no tools specifically built for either NHS or social care workers. Slow progress of clumsy digital initiatives that focus on the wrong thing, made worse by the fear of digital monsters. Lack of change and innovation. Lots of noise around schemes and gateways rather than actual solutions for real people. Layer the pandemic impact over these underlying issues and the position seems hopeless. It's not. “Data isn’t oil, it’s sand.” The tech industry has invested trillions of dollars and the time of millions of the world’s smartest experts. Much of this goes into solutions that capture and use epic quantities of data. Over the past 15 years, multiple standard, open source software tools and techniques have emerged that tackle exactly this kind of problem. Behind all the hype, hysteria and scaremongering, the current AI boom is just a manifestation of all this money and intellectual capital. It is outrageous that this is not used for the benefit of hard pressed frontline hospital staff. So what does this mean in practice? How can tools, like Triscribe, actually improve medication safety? Those 237 million errors include a lot of different things. Adverse drug reactions are just a small portion and the severe reactions are pretty rare. Using the existing data collected from a multiplicity of systems, we believe that more meaningful analysis is possible by: Reporting of adverse drug risks updated at least daily. Note: using a little AI, we can predict the risk of adverse drug reactions and give clinicians the information needed to stop at least some from happening. Much better than just reporting the incidents. Monitoring adherence key safety policies and guidelines. For example, VTE prophylaxis, allergy reviews and oxygen prescribing. Tracking and reporting late and omitted doses every day across all systems, including ward comparisons to identify learning and share better ways of working. Safe use indicators for specific medications; for example, early/ late administration of Parkinson’s medicines and opioid deprescribing. Reporting key compliance measures, including IV to oral switching for antibiotics, high dose prescribing of opioids and usage of methotrexate The possibilities are limitless. There is no shortage of data in the NHS. However, the ability to share that data between systems and organisations is something the health and care sector still lacks. It’s a solvable problem. Deliver quick, low-cost improvement using modern, open source software tools and techniques. We don’t need schemes and standards or metrics and quality control. The most important thing is to build software for the needs and priorities of frontline pharmacists, doctors and nurses. Keep learning and keep improving every day.
  4. Content Article
    Advice for healthcare professionals: be extra vigilant when prescribing and dispensing medicines with commonly confused drug names to ensure that the intended medicine is supplied if pharmacists have any doubt about which medicine is intended, contact the prescriber before dispensing the drug follow local and professional guidance in relation to checking the right medicine has been dispensed to a patient report suspected adverse drug reactions where harm has occurred as a result of a medication error on a Yellow Card or via local risk management systems that feed into the National Reporting and Learning System.
  5. Content Article
    The authors found that setting up ePrescribing systems was very difficult because there is a need to take into consideration how different pharmacists, nurses and doctors work, and the different work that needs to be carried out for different diseases and medical conditions. The authors recorded a link between the implementation of ePrescribing systems and a reduction in some high-risk prescribing errors in two out of three study sites. Given that the error reductions corresponded to the warnings triggered by the system, they concluded that the system is likely to have caused the error reduction. Prescribing errors may lead to adverse events that lead to death, impaired quality of life and longer hospital stays. The cost of an ePrescribing system increased in proportion to reduced errors, reaching £4.31 per patient per year for the site that experienced the greatest reduction in prescribing errors. This estimate is based on assumptions in the model and how much a health service is willing to pay for a unit of health benefit. To help professionals choose, set up and use ePrescribing systems in the future, the authors have produced an online ePrescribing Toolkit that, with support from NHS England, is becoming widely used internationally.
  6. Content Article
    In this longitudinal study, medication errors in the clinic, pharmacy, or at home among children with leukaemia or lymphoma over a 7-month period were common, and 10% suffered harm because of errors. Children on >13 medications had significantly more serious medication errors than those on fewer medications. Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%). Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering.
  7. News Article
    High 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
  8. Event
    This Westminster conference will discuss the strategic priorities for tackling overprescribing in the NHS. It follows NHS England’s overprescribing review and subsequent Good for You, Good for Us, Good for Everybody action plan. Delegates will discuss what would be needed if the plan’s aims for systemic and cultural change are to be achieved, and priorities for the proposed Clinical Director for Prescribing. It will be an opportunity to discuss the future of medicines optimisation, opportunities for social prescribing, and measures to enable consistent delivery across the whole population and to expand the workforce to deliver non-medical treatments where possible. Key areas for discussion include: culture change - including development of leadership and accountability around overprescribing at national and ICS level - key issues for the Clinical Director for Prescribing systemic change - the role of social prescribing - strategic priorities for medicines optimisation - practicalities of scaling up: funding, staffing, training, and engagement with patients patient-centred care - practical steps - involving patients with managing long-term conditions - building support and frameworks required for development research - sharing best practice and guidance - building the evidence base - developing understanding of the groups most impacted digital - the role of digital transformation in supporting patient-centred care and the ability to make more informed care decisions - improvements to patient records pharma - system-wide collaboration and industry transparency. Agenda Register
  9. Content Article
    OPTIMISE is a 62 indicator medicines optimisation tool designed to assist decision making in those treating adults with SMI. It was developed using a Delphi consensus methodology and interrater reliability is substantial. OPTIMISE has the potential to improve medicines optimisation by ensuring preventative medicines are considered when clinically indicated. Further research involving the implementation of OPTIMISE is required to demonstrate its true benefit.
  10. Content Article
    To share learning from clinical negligence claims with healthcare professionals, NHS Resolution has now published a suite of six information leaflets relating to medication errors. The ‘Did You Know’ series covers: Maternity Heparin and anticoagulants Extravasation High-level medication errors General Practice medication errors Anti-infective medication errors
  11. Content Article
    A medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention. An estimated 237 million medication errors occur in the NHS in England every year.[1] This number represents the sum of medication errors over all stages of the medication use process. Most errors occur during drug administration (54%), followed by prescribing (21%) and dispensing (16%). The majority of medication errors (72%) have little/no potential for harm, and only 2% have potential to cause severe harm. One of the recommendations to reduce medication errors and harm is to use the “five rights”: the right patient, the right drug, the right dose, the right route, and the right time. According to the NHS Patient Safety Strategy, “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". The NHS Medicines Safety Improvement Programme has been established to address the most important causes of severe harm associated with medicines and aims to reduce severe avoidable medication-related harm by 50% by March 2024. Prescribing errors can be reduced by incorporating decision support software into the electronic prescribing protocol, although many of the warnings generated by this type of software are of no clinical significance and are often regarded as an intrusion or an inconvenience and are usually ignored. A pharmacist’s signing off a prescription before it is dispensed will also capture potential prescribing errors. Dispensing errors are usually identified before the prescription is issued by a second check but with the introduction of dispensing/distribution robots in most hospital pharmacies, dispensing errors have almost been eliminated. The focus today is to reduce drug administration errors. In surveys, the most common errors were late or early administration of drugs or drug omission. Distractions and interruptions are a regular part of nurses’ working lives. If these occur when nurses are preparing and administering medicines, they can lead to drug errors that compromise patient safety. Poor numeracy and the need for complex calculations have also been highlighted as contributory factors to medication errors in both hospitals and in the community. However, many of these errors can be eliminated by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient. Individual doses should have machine readable codes on the label to ensure correct drug identification. Ready-to-administer injections (RTA) Injectable drugs should be made available in a ready-to-administer (RTA) format. The World Health Organization (WHO) defines RTA as “an injectable medicine that requires no further dilution or reconstitution and is presented in the final container or device, ready for administration or connection to a needle or administration set”. The preparation of IV medications at the bedside requires multiple steps and reducing these complex steps and manipulations can reduce the number of errors. Additionally, the use of prefilled RTA syringes can help reduce unnecessary wastage of medications by optimising pharmaceutical product size. Healthcare professionals responsible for administering injectable drugs should demand RTA preparations. In the first instance, hospital pharmacies should prepare high-risk injectable medicines in their aseptic compounding units or purchase them from third party contractors. Looking to the future, the pharmaceutical industry should offer licensed injectable medicines in a RTA format. Manufacturer-prepared RTA prefilled syringes can play an important role in simplifying these processes and reducing errors and potential patient harm. When contracts for injectable drugs are awarded, priority should be given to those products that are presented in a RTA format. Purchasing for safety must be implemented and not just discussed. Unit dose drug distribution (UDD) Unit dose drug distribution is a system that provides the prescribed dose of a specific drug for a certain patient at a specific time. It differs from other systems in that each dose of a prescribed drug is packaged individually, in a ready-to-administer form. Each dose is labelled so that it retains its identity right up to the time it is administered to the patient. The package, labelled with the drug name, strength, batch number, and expiry date, virtually eliminates contamination resulting from transfer and handling of the drug. Unused medications can safely be reissued. In addition, the system sharply reduces the potential for medication errors. For blister-packed tablets and capsules, separation of individual blisters and over-wrapping them in individual sachets has the advantage that the integrity and stability of the original pack is not compromised. Using a ‘closed-loop’ process where the patient, the drug and the healthcare worker are identified, a safer system for drug administration can be established using unit doses with the added advantages of reduced drug wastage, reduction in nursing time and reduced inventory on the ward. Medication errors, particularly drug administration errors can be reduced considerably by redesigning packaging, eliminating the preparation of doses in clinical areas and simplifying the medicine rounds. This can all be brought about at no overall additional cost to the healthcare provider by utilising the efficiencies generated by the new practices. Reference 1. Elliott RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf 2020:1-10. doi:10.1136/ bmjqs-2019-010206.
  12. Content Article
    WHO states that medication harm accounts for around 50% of the overall preventable harm in medical care and comes with a huge financial cost, estimated at $42 billion USD annually. Patients can be subject to avoidable harm as a result of medication in a range of different ways, including: prescription errors—being underprescribed or overprescribed medicines or receiving a prescription which does not address the health condition and subsequently results in deterioration. dosage errors—missed doses or incorrect doses, which can occur in a range of different settings. mistakes in administration—such as administering a medicine which should be take intravenously by the intrathecal route. Global Patient Safety Challenge This year World Patient Safety Day, on Saturday 17 September 2022, is focused on medication safety. It is intended to build on the existing WHO Global Patient Safety Challenge: Medication Without Harm. Formally launched in 2017, the aim of this is to reduce severe avoidable medication-related harm by 50% in the next five years. This challenge focuses on three key action areas: Medication safety in polypharmacy—this concerns is the concurrent use of multiple medications. Although there is no standard definition, it is often defined as the routine use of five or more medications. Medication safety in high-risk situations—this concerns circumstances where the medication being used may be associated with a particularly high risk of harm, where provider and patient factors that may increase the level of risk and where system factors (work environment) that may increase the level of risk. Medication safety in transitions of care—this concerns the various points where a patient moves or returns from a particular physical location or makes contact with a healthcare professional for the purposes of receiving healthcare, Each of these actions are mapped against four different domains where greater awareness and action is required: 1. Patients and the public Public awareness and medication literacy Patient engagement Reporting by patients Involvement of patient organisations 2. Health care professionals Education and training Communication and teamwork Capability at point of care Incident reporting and learning 3. Medicines Product quality and safety Naming, labelling, and packaging Logistics, storage, and disposal Right product at point of care 4. Systems and practices of medication Leadership and governance Prescribing, preparation, and dispensing Administration and patient monitoring Monitoring and evaluation 5 Moments for Medication Safety tool As part of this Challenge, WHO has developed a patient engagement tool: 5 Moments for Medication Safety. This looks at the key points where a patient or carer can reduce the harm associated with the use of medication/s, with the intention of empowering them to be involved in their care and patient safety. Medication Safety webinar series WHO has recently run a series of excellent webinars with global experts, healthcare professionals and patients, to introduce the strategic framework for implementation of this Global Challenge. These include strategies, tools, and technical support to countries for reducing medication-related harm, in addition to sharing country and patient experiences of implementing the challenge. Recordings and presentations from each of these webinars can be accessed below: WHO Global Patient Safety Challenge: Medication Without Harm & World Patient Safety Day 2022 (8 February 2022) Engaging Patients and Families for Medication Safety (8 March 2022) Medication Error Reporting and Learning Systems, and Pharmacovigilance (12 April 2022) Medication Safety in High-risk Situations (17 May 2022) Medication Safety in Transitions of Care (7 June 2022) Medication Safety in Polypharmacy (12 July 2022) Related reading You can find a wide range of articles related medication safety, including research, risks, opinion pieces and examples of good practice, on the hub. You can also find a number of examples of medication error traps, situations which could lead to avoidable harm if not mitigated, on the hub error traps gallery.
  13. Content Article
    Patients for Patient Safety (PFPSUS) is a network of people and organisations aligned with the World Health Organization (WHO) and focused on making healthcare safe in the United States. In this article they explain why Vanderbilt University should be held accountable for their faults. PFPSUS have requested that the U.S. Office of the Inspector General investigate Vanderbilt, the Tennessee Department of Health and CMS to determine if they followed appropriate laws and procedures related to the reporting of this error. Among the questions posed are: Did the Tennessee Department of Health take appropriate legal action when Vanderbilt did not report the error? Did Vanderbilt commit Medicare fraud when they attributed the cause of death as “natural” on the death certificate? Did CMS appropriately impose any consequences within their powers that addressed Vanderbilt’s manipulation of patient data and failure to report the error? Did Vanderbilt’s actions and omissions violate CMS Conditions of Participation and if so, why weren’t actions taken?
  14. Content Article
    Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue causing trauma. From 1 April 2010 until the 1 December 2021, NHS Resolution received 467 claims relating to extravasation injuries. This virtual forum featured a panel discussion with the following speakers: Andrew Barton, Chair of NIVAS and IV nurse consutlant (NIVAS and Frimley NHS Trust) Alison Macefield, Deputy Head of Midwifery (Royal Devon and Exeter NHS Foundation Trust) Jorge Leon-Villapalos, Consultant in Plastic Surgery and Burns (Chelsea & Westminster) Lisa-Marie Musgrave, Senior Claims Manager (NHS Resolution) Samantha Thomas, Associate Safety and Learning Lead London (NHS Resolution) Presentations from this session can be found below: Extravasation: Learning from claims (NHS Resolution) NHS Resolution extravasation presentation 2022 PDF.pdf Extravasation injuries: Recognition and clinical Management (Jorge Leon-Villapalos) EXTRAVASATION INJURIES JLV PDF.pdf Complications of IV therapy: Extravasation (Andrew Barton) NIVAS extravasation presentation 2022 Andrew Barton PDF.pdf Related reading Extravasation: a patient safety priority (28 June 2022) NHS Resolution report – Extravasation (15 March 2022)
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