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News Article
Missed and delayed medication putting A&E patients at risk, new report reveals
Patient Safety Learning posted a news article in News
Patients in A&E are being put in potentially life-threatening situations due to missed doses of prescription medicines, according to a new report. The Royal College of Emergency Medicine (RCEM) found people in A&E were not getting their medications on time and were missing doses needed to manage their illnesses – putting them at risk of getting worse. Insulin for diabetes, Parkinson's drugs, epilepsy medicines and tablets for preventing blood clots are all time critical medicines (TCM). If these drugs are delayed or missed, the patient can deteriorate and is at greater risk of complications or death. While patients are advised to remember to bring their medications to A&E and to take them, there is also a responsibility on NHS staff to make sure this happens. Despite the recognised risk of harm, the delivery of TCM is not consistent across emergency departments with long waiting times often contributing to this. The study, which was part of the College's clinical Quality Improvement Programme (QIP) which aims to improve the care of A&E patients, found more than half of these patients were not identified as being on TCM within 30 minutes of their arrival in an emergency department. In addition, 68% of doses were not administered within 30 minutes of the expected time. "The findings contained in this report should serve as a call to action for both emergency medicine staff, as well as patients reliant on time critical medications, to ensure no dose is ever missed in A&E," said Dr Jonny Acheson, an emergency medicine consultant in Leicester who has Parkinson's, led the study. Read full story Source: The Independent, 7 April 2025 Further reading on the hub: Time-critical Parkinson’s medication: the human cost of delays and mistakes HSSIB investigation report: Medication not given: administration of time critical medication in the emergency department Parkinson's UK: Time critical medication guides for health professionals Improving safety for diabetic inpatients: 4 key steps D1abasics: Equipping staff to care safely for inpatients with diabetes -
Content ArticlePatient safety is being put at risk in Emergency Departments due to missed doses of vital prescription medicines. This is one of the findings of a study being carried out by the Royal College of Emergency Medicine (RCEM) which revealed that many patients who rely on prescription medication to manage chronic conditions such as diabetes and Parkinson’s, aren’t always getting these vital drugs when in A&E. These types of drugs are known as ‘time critical medication’ (TCM) and, as the name suggests, it is important they are taken at specific times. If a dose is delayed or missed, it can cause a person’s health to worsen. And if this delay is prolonged, the consequences can be severe. The RCEM’s new report – Time Critical Medication QIP 2023-24 is part of the College’s clinical Quality Improvement Programme (QIP), which aims to improve the care of patients attending Emergency Departments. The three-year QIP examines how time critical medications are dealt with in practice when patients come to the Emergency Department and how clinical methods and patient safety can be improved. This report reflects the findings of the first year of the programme. Across the UK, 136 Emergency Departments collated and analysed data for people living with diabetes and Parkinson’s, who take certain medication such as insulin injections and a drug called levodopa, taken as tablets or capsules. Supported by Parkinson’s UK and Diabetes UK, the QIP found more than half of eligible patients (53.4%) taking TCM weren’t identified within 30 minutes of their arrival in ED. Meanwhile, around 68% of eligible patients’ doses weren’t administered within 30 minutes of the expected time. In response to the findings, the QIP team made the following recommendations: Patients on TCM need to be identified early to start the process of getting all doses whilst in the ED. Systems need to be in place that will facilitate the timely administration of TCM, including self-administration. Local EDs must have a clear governance structure in place to determine who is responsible for the prescribing and administering of TCM in the ED from when the patient arrives, to when they are admitted to the ward or discharged from the ED. Further reading on the hub: Time-critical Parkinson’s medication: the human cost of delays and mistakes HSSIB investigation report: Medication not given: administration of time critical medication in the emergency department Parkinson's UK: Time critical medication guides for health professionals Improving safety for diabetic inpatients: 4 key steps D1abasics: Equipping staff to care safely for inpatients with diabetes
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Content Article
Specialist Pharmacy Service: Medication safety update
Patient Safety Learning posted an article in Medication
A resource collating the latest medication safety communications and publications to inform, support and inspire medication safety improvements. Each month the SPS Medicines Advice team gathers and reviews recent medication safety communications, reports, publications and practice research. The slide deck resource includes items considered pertinent to supporting or delivering against the medication safety agenda. Items include: Medication related safety alerts and notifications. Summary of Product Characteristics (SPC) changes. Risk minimisation materials. Medication shortages and discontinuations. Publications and reports. Prevention of Future Death Reports (Regulation 28) recommendations. Primary research papers on medication safety. -
Content ArticleParents and carers play a critical role in supporting their children while in hospital. Multiple qualitative studies have explored parental involvement in the care of hospitalised children. Administration of medication to young children can be difficult and cause anxiety and stress for children. Parents are often willing and able to assist, yet little is known about how often parents are given responsibility for medication administration in hospital. This study analysed data from a prospective direct observational study of nurses administering medication at a major paediatric referral hospital in Australia. Data from observations of 298 nurses preparing and administering 5137 medication doses to children on nine medical and surgical wards between 07:00 and 22:00 were analysed. Details of drugs administered, whether medications were left for parents/carers to administer, and if nurses observed the administration by parents, were recorded. Parents were at their child’s bedside during 89.7% of observed medication administrations. Parents gave 20.3% of medications. In 14.3%, medications were left with parents to administer without a nurse present. In 6.1% of doses, medications were given to parents, but the administration was observed by a nurse. Parents were most likely to be given medications to administer to young children (1–5 years), and the medications most frequently administered were analgesics and anti-epileptics. Parents/carers are integrally involved in the administration of many medications to children in hospital. The extent of parents’ role and the impact on medication administration efficiency has been largely absent from the healthcare literature. Given that one in five medication doses is administered by parents, hospitals should recognise this contribution and consider if any additional support for parents is required.
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Content ArticleThis study from Spain investigated the factors influencing medication errors made by informal caregivers while providing care at home. It found that errors made by informal caregivers occur more frequently than expected, and recognising these errors remains a challenge. Training is essential for creating safer care environments by increasing awareness of error sources and the risks associated with medication. Recipients’ direct relatives should receive appropriate training, considering differences between male and female caregivers. Associations and companies within the care economy sector should prioritise the creation of safer home care environments as a key objective.
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Content ArticleSublingual nitroglycerin (Nitrostat) is a nitrate vasodilator used to treat episodes of chest pain in patients who have coronary artery disease. The tablets are supplied in small, amber bottles that are tightly capped to keep out light, moisture, and air. The loss of potency from environmental exposure often prevents repackaging of the tablets from a multidose bottle into single doses. Therefore, without single doses pre-packaged ahead of time and proper safeguards to warn against the multidose bottle, an overdose of up to 25 times the intended dose can occur. This study examines reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing unintended dispensing and administration of whole bottle contents. These incidents have resulted in patients needing to be resuscitated and transfer to a higher level of care.
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Content ArticleA multidisciplinary team at Birmingham Women’s and Children’s NHS Foundation Trust developed an extravasation care bundle that integrates a red, amber and green extravasation risk rating system for all intravenous medicines, and offers a standardised approach to observing intravenous access sites and tracking infusions to enhance safe care delivery. This initiative has led to reduced incidence and harm from extravasations. Next steps involve collaborating with external experts to develop technological solutions to further improve safety and reduce incidence and harm. Related reading on the hub: National campaign aims to reduce patient harm from infiltration and extravasation Infiltration and Extravasation: A toolkit to improve practice
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Content ArticleIn a dynamic healthcare environment, patient safety is crucial. A "Conscious Actions Reduce Errors" (C.A.R.E) approach is needed to safeguard safety and reduce medical errors. The dual process theory highlights two thinking modes: intuitive (fast, automatic) and analytical (slow, deliberate). Intuitive thinking, though quick and often effective, can lead to cognitive biases like anchoring and availability heuristics. A C.A.R.E approach incorporating tools like the TWED checklist (Threat, What if I'm wrong? What else?, Evidence, Dispositional factors) and Shisa Kanko (Japanese method of pointing and calling) can help to improve decision-making and action precision in clinical settings.
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Content Article
Hi, my name is Andrew Payne. In October 2019, my late wife Janice was in the palliative stage of her cancer when she was a victim of a dispensing error. This was caused in large part by an intransigent pharmacist who refused me an emergency supply of medication for my wife a few days previously. Failures by the pharmacy branch and Janice's GP meant she had to endure the side effects of ingesting the medication of a patient with the same surname as her. She will have suffered pain, discomfort and harm. This much has been admitted by the private pharmacy company involved. I would like to share the series of events leading to my wife's death and after, and the actors involved and the questions that need to be answered. The pharmacy As much as the pharmacy involved said "we take this kind of circumstance very seriously", the truth is that they worked very hard to see the case closed. The pharmacy did not mention to me the failures of their staff to observe the Duty of Candour. They did not direct me to the industry regulator. Instead, I was advised that this case was being reviewed by their ‘customer complaint process’ and I was sent a ‘customer charter’. Their process gave the pharmacy a 20-day cushion for them to thoroughly investigate the error and in this time they batted away my questions and queries. Their own internal investigation found nothing untoward apart from the terrible human error of a lady behind the counter who served me as the pharmacist refused (against company and industry guidelines) to come out herself to see if my request for the emergency medication had merit or not. I made a complaint to the General Pharmaceutical Council (GPhC) and they found sufficient evidence to open an investigation. A pharmacy executive was unhappy about this and made efforts to assure the GPhC that this was a simple case of human error despite knowing that this was in fact more than a simple case of human error. The pharmacy executive went on to convince the GPhC investigators that they did not need to question the pharmacy staff that they had identified to take statements from, and, instead, this ‘non-involved’ executive became the single witness representing everyone. The insurers I was witness to the harmful influence of insurers, who indemnify healthcare professionals causing them to question their actions in an error circumstance. When the pharmacy company introduced me to their indemnity insurer, I conducted an internet search and found a piece of advice to their pharmacist members on the National Pharmacy Association website on how to react in a dispensing error circumstance. In my opinion this advice was written by a legal executive and I suggest it is an invitation to their members to breach their professional duties to their patient. When I discovered this, I advised the pharmacy company that their branch team had followed this advice almost to the letter. This triggered unseemly actions by both the pharmacy and the insurer. I had many exchanges with them in which I invited them to remove this terrible advice from their website, but was told this is typical advice, and of course it is, but this comes in the form of ‘deny liability’ and represents a threat to all NHS patients. The National Pharmacy Association did eventually removed this when the Chief Pharmaceutical Officer for England at the time became involved. I was unable to convince the GPhC that their investigation was corrupted and, therefore, invalidated. The regulator The GPhC took 18 months to take statements from the pharmacy executive and myself, consider the factors and make their decision. I called their investigation ‘a parody’. I was beside myself with astonishment and despair to see that they did not include the breaches in the Duty of Candour in their investigation. I received an unsigned letter from the ‘outsourced’ solicitor company investigators. I was advised that they had found the pharmacy company to have acted positively to the error and that there were no grounds for further action. I wrote a strong letter of discontent, in which I reminded the CEO of the regulator that he was a signatory to the joint statement on the Duty of Candour in 2014. To his credit, he commissioned an outsourced review of the handling of the case. Unfortunately for the cause of finding the truth, learning lessons and doing the right thing, this review was poor. There were aspects of the review that the CEO did not agree with and he ordered that the case should be reviewed again. Seven months of ‘investigations' later, it came to the same conclusions as the first investigation, albeit with a more wordy outcome letter. Janice and I, as the ‘public being protected’ by this regulator, had been failed on a monumental scale. Putting patients in harm's way I have looked behind these fine words and promises to protect the public to find a different set of interests being placed before the public. I have seen the betrayal, not just of the GPhC but also of other regulators. I have seen the flaws in the authority tasked with overseeing these healthcare regulators and I have seen the depth of failure. I was forced by the GPhC to use the Freedom of Information Act to learn otherwise undisclosed details of my case. I found this Act a crucial mechanism as I was able to ask questions of the regulators. I have used the Act to ask the same questions to NHS Trusts and I have compared the results to see how much safer the public are when they are being cared for by the NHS. That is to say, if an error occurs and this happens within a facility operated by the NHS, are there are better systems in place. I am very fearful to see community services operating from NHS facilities. I see this as exposing patients to harm. I am committed to seeing changes introduced that will see the public made as safe as it is possible to be. Difficult questions asked I finish this story with the difficult questions I have asked. All of these queries resulting from one case. Why is it possible for two healthcare professionals working in the same NHS facility to be regulated differently when it comes to the Duty of Candour? For example, a nurse working in the NHS facility will be regulated by the Nurses and Midwives Council (NMC) and thus governed by the professional Duty of Candour. If a nurse breaches the Duty of Candour they will be investigated by the NMC and the Care Quality Commission (CQC) will be responsible for investigating the NHS facility as the organisation is responsible for its staff to adhere to the Duty of Candour. However, community pharmacies operating within the NHS facility are not regulated in the same way. The GPhC (and other regulators) are not mandated to ask whether the pharmacist under investigation was supported or trained by their employers. Why are there better systems in place for patients when their NHS services are provided by the NHS rather than by a private company? In the NHS the employers have a marked responsibility to ensure that their staff are updated, informed and observe their professional duties. This is because the CQC are policing a statutory duty and a breach in this duty is a breach in law. Why aren’t private companies providing NHS services, such as pharmacies, required to meet NHS standards? Why aren’t private companies regulated for the part of their business which provides NHS services to NHS patients? Why aren’t standard operational procedures standardised across the private companies providing NHS services to NHS patients? When ‘something goes wrong’ with an NHS patient receiving an NHS service from the private sector, why is it the NHS picks up the costs of ‘harm done’? Why are insurers allowed to undermine the integrity of professionals in the conduct of their duties? It is inevitable that when an error has occurred, a professional's thoughts turn to the possible impact on their future, and so it is not surprising that a call to an insurer is made before following employer standard operating procedures and professional guides. In our case, the GP failed to alert the coroner of the dispensing error and only did so following a call to his indemnity insurer. Why are unregistered professionals working in healthcare exempt from sanction? Why are regulators allowed to make false claims of ensuring public safety? Janice Payne needs to be the last NHS patient failed by needless neglect. We need to act now in the name of public safety. Further reading on the hub: How to make a complaint How do I make a complaint: Sources of help and advice -
Content ArticleStandardised nomenclature for combination formulations could “minimise confusion and prevent medication errors”, suggests the authors of this study. The authors identified 26 combination formulations with ‘co-drug’ names in the UK. Eleven were prescribed more than 2,000 times during 2023, including paracetamol + codeine (co-codamol), which saw an average of 1.26 million items dispensed each month; carbidopa + levodopa (co-careldopa – 114,656 items a month); dihydrocodeine + paracetamol (co-dydramol – 110,506 average monthly items; and amoxicillin + clavulanic acid (co-amoxiclav), with an average of 106,504 items a month. A literature review found examples of errors involving, with decreasing frequency, co-amoxiclav, co-amilofruse, co-beneldopa, co-careldopa, co-codamol, co-dydramol and co-trimoxazole. The authors noted that packaging of co-drugs can also be inconsistent. For example, some co-codamol products do not prominently display the individual active ingredients, while the strength is unclear on others. To reduce the risk of errors, the authors advocate a standardised nomenclature on the box and in prescribing resources so that the international non-proprietary name (INN) of each component is followed by the strengths in the x + y format.
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EventuntilJoin the Parkinson's Excellence Network for our time critical medication virtual webinar. Our expert panel will share their experience of time critical Parkinson’s medication and benchmarking. Join the discussion, identify appropriate actions for your organisation and learn about the support for health professionals. Learning outcomes for the session: Share experience on time critical Parkinson’s medication and benchmarking. Be familiar with the 10 recommendations for time critical medication. Identify appropriate actions for your organisation. Navigate the further resources and support that are available for health professionals. View the draft agenda and register to attend now on the Parkinson's UK website.
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Content ArticleThis multi-award winning video*, produced in 2003 was commissioned by the office of Sir Liam Donaldson and produced by UCL Images, a video production centre based at University College London. The video illustrates updated guidance from the Department of Health on safe administration of intrathecal administration. *Please note that this is a copy of the video as this video is no longer available to order from the Department of Health. The video clip has been made publicly available from a poster on YouTube.
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News Article
Elderly patient left unable to swallow after 52-hour A&E wait
Patient Safety Learning posted a news article in News
An elderly man was left unable to swallow after waiting over two days in A&E without being given regular medication, and died four weeks later. In a “shocking” case that has raised fresh concerns over the state of urgent NHS care, the 85-year-old was sent to a hospital emergency department after a routine appointment. Amid massive delays, his A&E wait went into a third day, with most of it spent on a bed in the corridor. He had Parkinson’s disease and required medicine at various intervals to control his symptoms. During his time in A&E, the man should have received 18 doses but seven were not given and three were given late, according to a report from the Health Services Safety Investigations Body (HSSIB). The report, which does not name the patient or hospital, highlights how the man was advised to go to A&E after complaining of back pain following a fall at home the day before. After 52 hours in A&E, he was finally admitted to a ward where his Parkinson’s symptoms deteriorated and he lost the ability to swallow, the HSSIB said. He died four weeks later, with the causes of death listed on the death certificate as a severe chest infection, Parkinson’s and frailty of old age. The HSSIB report highlights how the man spent most of his time in A&E on a bed in a corridor because of demand on services. Corridor care can cause problems for emergency staff because there are “limited opportunities to store medication brought from home”, the authors said. Read full story Source: The Guardian, 5 November 2024 Further reading on the hub: Professionals with Parkinson’s tackle time critical patient safety issue: a blog by Sam Freeman Carney Parkinson's UK: Time critical medication guides for health professionals Medication delays: A huge risk for inpatients with Parkinson’s A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift -
Content ArticleThis is the first in a series of Healthcare Services Safety Investigation Body (HSSIB) investigations exploring why medications intended to be provided to patients are not given. Patients who need medications can suffer harm if these are not provided. The investigation explored the systems and processes in place to support staff to recognise, prescribe and administer time critical medications in the emergency department (ED). Time critical medications are medications that must be given at specific times of the day to ensure they are fully effective. The investigation also explored the role played by electronic prescribing and medicines administration (ePMA) systems in supporting care in this area. To explore these issues, the investigation used a patient safety event involving a patient aged 85 with Parkinson’s. The patient usually took his own medication (self-administered) at home – two doses of Parkinson’s medication four times a day, at set times – to help control his symptoms. The patient safety event The patient had attended hospital for an outpatient appointment where he mentioned he had back pain following a fall at home the previous day. He was advised to attend the ED and went there immediately after his outpatient appointment. The patient spent 3 days in the ED. During this time he should have received a total of 18 doses of his Parkinson’s medication, which was a time critical medication. However, seven doses were not given and three doses were given late. This meant that only 8 of 18 doses of Parkinson’s medication were provided to the patient on time. The patient was transferred to a medical ward where his Parkinson’s symptoms deteriorated and he lost the ability to swallow. The patient died 4 weeks after his admission to the ward. The causes of death identified on his death certificate included bronchopneumonia (severe chest infection), Parkinson’s, and frailty of old age. Findings The patient required time critical medication for Parkinson’s but did not receive, or received late, 10 of 18 doses during his time in the ED. The coroner reported Parkinson’s as a factor leading to the patient’s death. There were no defined roles or responsibilities in the ED to ensure patients who required time critical medications were identified, and medications prescribed, as soon as possible. The ED had no dedicated pharmacy support to help staff in providing care to patients who required time critical medications. The patient spent 52 hours in the ED; for 44 of these he was cared for in a corridor because of demand on ED services. Corridor care created additional challenges for ED staff and specialty teams and may have limited opportunities to store the patient’s medication which he had brought from home. The Trust did not participate in the Royal College of Emergency Medicine Quality Improvement Programme on time critical medication. The ePMA system did not include a function to alert staff about patients who required time critical medications to be prescribed or administered. An outage in the ePMA system meant the patient required both an electronic and paper prescription chart. This may have caused additional confusion about the patient’s medication. Staff had adapted their practice to ensure they could effectively use the ePMA in the ED setting. This was because of challenges in accessing computers and medication rooms in the ED environment. The patient self-administered some doses of his Parkinson’s medication, but this was not planned and self-administration by patients was not widely supported by clinical staff or local guidance. Staff were not able to check neurology clinic letters because there was a backlog in these letters being uploaded to the electronic patient record system. Staff were not able to check information with the patient’s GP practice or Parkinson’s specialty team at the time the patient’s medication was prescribed in the ED, as this was outside of these services’ working hours. Staff received contradictory information from the patient’s son and the GP summary care record about the dosage of medication the patient required. The GP summary care record was taken as the most accurate record, but the information it contained was incorrect. Once the patient’s medication information was entered onto the ePMA system, no further attempt was made to contact the GP practice or Parkinson’s specialty team to confirm it was correct. Some information about the patient’s medication within the GP patient record was transferred to the GP summary care record, but other information was not. Safety observation NHS trusts can improve patient safety by using the information contained in the information pack for the Royal College of Emergency Medicine’s Quality Improvement Programme on time critical medications to assess their preparedness and make local improvements in identifying, prescribing, and administering time critical medications in emergency departments. Local-level learning prompts for acute hospitals Delays in identifying and prescribing time critical medication in the ED How does your organisation ensure that patients who need time critical medications are identified as soon as possible on arrival to the ED? Who in your patient pathway is responsible for identifying patients who need time critical medications? Who in your patient pathway is responsible for prescribing time critical medications? How does your organisation ensure that once a patient’s need for time critical medications is identified, they are prescribed? What aids or tools are available in your organisation to help staff to identify patients who need time critical medications? What pharmacy support is available to staff in ED to support in the care of patients who need time critical medications? Missed and delayed doses of time critical medication in the ED How does your organisation support staff to access information (including information from primary care and specialty teams) about patients’ time critical medications? How does your organisation support patients to self-administer time critical medications, when appropriate? How does your organisation capture information when patients self-administer time critical medications? How does your organisation receive and consider information from families and carers to help avoid missed or delayed doses of time critical medications? ePMA systems and time critical medication in the ED How does your ePMA system help to alert staff to patients who need time critical medications? How does your organisation train staff to use local ePMA systems and record when patients require time critical medications? How does your organisation prepare and support staff to work safely when ePMA systems may not be functioning to ensure time critical medications are not missed? How does your organisation audit delays or omissions in time critical medications and use this to improve delivery of time critical medication? Is your organisation aware of any adaptations that staff are required to make to ensure they can use the ePMA system effectively in local environments? Further reading on the hub: Professionals with Parkinson’s tackle time critical patient safety issue: a blog by Sam Freeman Carney Parkinson's UK: Time critical medication guides for health professionals Medication delays: A huge risk for inpatients with Parkinson’s
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Content ArticleThis article by BD looks at the the risks related to irritants and vesicants when medications are administered to patients via vascular access (into their blood vessels through a cannula). It highlights the immediate risks of vein irritation, pain, discomfort and potential tissue damage during an infusion, as well as looking at the impact of damage to vascular endothelial cells caused by irritants and vesicants. It offers guidance on selecting the right vascular access device (VAD) and includes a Vascular Access Device Assessment Decision Tree, which is free to download.
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News Article
New time critical medication resources for health professionals launched
Patient Safety Learning posted a news article in News
Three new resources have been launched by the Parkinson’s Excellence Network to support UK healthcare professionals in hospitals to improve the delivery of time critical medication for people with Parkinson’s: An interactive resource showing which NHS organisations have pledged action on time critical medication. Access the map now. Benchmarking to improve the delivery of time critical medication at South Tyneside and Sunderland NHS Foundation Trust: best practice case study. Read the case study. Self administration: a patient-centred approach to administering time critical Parkinson’s medication at University Hospitals of Leicester NHS Trust: best practice case study. Find out more about self administration. You can read more about all of this and more in the latest time critical medication blog. Access all of the time critical medication resources. Source: Parkinson's UK, 4 November 2024 -
Content ArticleParkinson's UK spoke to Hannah Flint, Senior Nurse Medicines Management, and Joanne Mee, Medicines Management Nurse, to find out how the University Hospitals of Leicester (UHL) NHS Trust has empowered patients by developing a robust self administration policy supported by staff training.
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Content ArticleHealthcare professionals are reminded to inform patients about the common and serious side effects associated with glucagon-like peptide-1 receptor agonists (GLP-1RAs). Advice for healthcare professionals: Inform patients upon initial prescription and when increasing the dose about the common risk of gastrointestinal side effects which may affect more than 1 in 10 patients. These are usually non-serious, however can sometimes lead to more serious complications such as severe dehydration, resulting in hospitalisation. Be aware that hypoglycaemia can occur in non-diabetic patients using some GLP-1RAs for weight management; ensure patients are aware of the symptoms and signs of hypoglycaemia and know to urgently seek medical advice should they occur. Patients should also be warned of the risk of falsified GLP-1RA medicines for weight loss if not prescribed by a registered healthcare professional, and be aware that some falsified medicines have been found to contain insulin. Be aware there have been reports of potential misuse of GLP-1RAs for unauthorised indications such as aesthetic weight loss report suspected adverse drug reactions to the Yellow Card scheme.
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Content ArticleDrug-related errors are a leading cause of preventable patient harm in the clinical setting. Chan et al. present the first wearable camera system to automatically detect potential errors, prior to medication delivery. The authors demonstrate that using deep learning algorithms, the system can detect and classify drug labels on syringes and vials in drug preparation events recorded in real-world operating rooms. They created a first-of-its-kind large-scale video dataset from head-mounted cameras comprising 4K footage across 13 anaesthesiology providers, 2 hospitals and 17 operating rooms over 55 days. The system was evaluated on 418 drug draw events in routine patient care and a controlled environment and achieved 99.6% sensitivity and 98.8% specificity at detecting vial swap errors. These results suggest that the wearable camera system has the potential to provide a secondary check when a medication is selected for a patient, and a chance to intervene before a potential medical error.
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EventThis conference focuses on improving practice and patient safety to reduce extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce extravasation injury. Learn from outstanding practice in recognizing, treating and escalating extravasation injury. Reflect on national developments and learning. Ensure vesicants are administered in the safest way. Develop your skills in training frontline staff to recognise evolving injuries. Understand how you can implement preventative measures. Identify key strategies for improvement. Educate patients to raise alarm and improve consent procedures. Develop protocols to support practice. Understand the role and competencies of the NHS trust lead for extravasation. Ensure effective treatment, and early intervention in severe wounds. Learn from case studies in cancer, maternity, radiology and paediatrics. Ensure you are up to date with the latest legal cases. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/iv-therapy-summit-2023 or email [email protected] Follow on Twitter @HCUK_Clare #IVTherapy hub members receive a 20% discount. Email [email protected] for discount code.
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Content ArticleRizwana Dudhia shares in the Pharmaceutical Journal how a project she initiated to prevent the prescribing of inappropriate medication improved the quality of life for patients with learning disabilities and autism.
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Content Article
Better use of data for medication safety in hospitals
Kenny Fraser posted an article in Medicine management
NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. In this blog, Kenny Fraser, CEO of Triscribe, explains why we need to 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. 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. -
Content ArticleMedication error may occur for a variety of reasons. One of the most common sources of medication error is related to look-alike and sound-alike (LASA) drugs as well as the often-similar appearances of the vials. LASA medications are typically thought of as medications that are similar in physical appearance related to packaging as well as medications whose names are similar in spelling or in the phonetic pronunciation. Tricia A. Meyer looks at cases of LASA drugs and prevention techniques. She concludes that healthcare professionals, safety groups, and professional organisations should continue to work with manufacturers, regulators, and naming entities to explore opportunities to minimise the LASA risks for drugs that are either new to the market or in the pre-marketing stage. Further information on the hub Take a look at our Error traps gallery on the hub
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Content ArticleThis report summarises the findings arising from a comprehensive study of antibiotic ‘line flushing’ and disposal practices in NHS organisations across Great Britain. It argues that is a need for concerted, UK-wide action on antibiotic line flushing policies. ‘Line flushing’ is the act of pushing an appropriate diluent, such as saline, through the tubing connecting patients with infusion bags which contain medicines. Up to 1/3rd of the total dose prescribed by clinicians can remain sequestered in un-flushed tubing, resulting in patients receiving too little of the antibiotic they need to fight infection. This acts as a driver for antimicrobial resistance (AMR), potentially making patients more susceptible to future drug-resistant infections (DRIs) with their associated morbidity, mortality, and costs to the NHS. This report highlights the following findings in relation to this: Fewer than 1 in 3 (29.1%) responding NHS organisations across Great Britain have an antibiotic line flushing policy. Of these, only a minority (43.8%) are fully compliant with their own policies. Overall, only 12% of NHS organisations in Great Britain—fewer than 1 in 8—are fully compliant with their own established antibiotic line flushing policies. Fewer organisations still have audited compliance in a measurable way: only 1 in 20 (5.1%) responding NHS organisations have done so. Scotland leads the way in designing and implementing antibiotic line flushing policies, followed by Wales, with English NHS organisations trailing behind. A large number of NHS organisations do not engage in line flushing dispose of antibiotics inappropriately, such as in unsealed containers (e.g. medical waste bags). A substantial proportion of NHS organisations in Great Britain dispose of administration sets in unsealed containers such as medical waste bags. In addition, a small minority of NHS organisations in Great Britain (up to 17.3%) do so without separating the spike from the administration set, against organisational policies to dispose of spikes in sharps bins and thus potentially causing occupational hazards. The report makes five policy recommendations: That all NHS organisations implement line flushing policies by late 2024, with support from the Department for Health and Social Care. That national regulators integrate adherence to line flushing policies into their assessment framework when assessing hospitals. That Government funds be made available to enable research into underdosing’s impact on DRIs and environmental AMR. That comprehensive training be provided to all appropriate staff surrounding how to dispose of antibiotics appropriately. That hospitals monitor environmental antibiotics contamination, both in effluent and on wards. Related reading Short-term intermittent IV antibiotics – Understanding the issue of under delivery Understanding the importance of accurate antibiotic administration through an IV administration set (drip): A patient’s guide Top picks: 10 key resources on antimicrobial resistance
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Content ArticleAmbulatory infusion pumps are small, battery powered devices that allow patients to carry out day-to-day activities while receiving medication. They are used for many healthcare needs, including symptom relief during palliative care, and in different settings including hospitals, hospices and patients’ homes. Despite having audio and visual warning alarms to notify when medication is not being delivered as it should be, there is a risk that alarms can go unnoticed, particularly by healthcare staff in inpatient settings. The patient case in the Health Services Safety Investigations Body (HSSIB) investigation report is Stephen, a 45-year-old cancer patient on palliative care in hospital, who did not receive his pain relief medication for six hours. Over the course of six hours, there were eight warnings. The investigation An investigation was carried out to explore factors that can affect the ability of patients to reliably receive their medication via an ambulatory infusion pump. The focus was on this specific type of device as they are used widely across healthcare providers in England for patients receiving palliative care. The investigation uses ‘hazard’ to describe something that has the potential to cause harm or have an adverse effect on a patient. A ‘control’ is a measure put in place to reduce the risk of a hazard occurring. The investigation focused on: Equipment controls that enable effective delivery of medication. Environmental and staff factors that can influence the monitoring of medication delivery via ambulatory infusion pumps. Findings Current ambulatory infusion pump alarms may not effectively notify staff of hazardous situations (situations where intervention by a healthcare professional is needed because there is potential for harm to a patient). Alarms may occur, but if staff are not alerted to them, the required interventions may not take place. Current national reporting systems are complicated and do not support the capture and sharing of medical device related incidents across appropriate national bodies. To enable the effective cross organisational sharing of incident data local incident reporting systems, which feed into the NHS England Learn from Patient Safety Events service, would need to meet the Medicines and Healthcare products Regulatory Agency (MHRA) data standards. The main factors that affect staff’s ability to hear an alarm and intervene in a hazardous situation are the infrastructure and working environment in which infusion pumps are used. When staff cannot hear or see an alarm, outside of the 4 hourly infusion pump staff checks, they are reliant on patients or families to alert them to issues with an ambulatory infusion pump. This is not always possible when the patient is unwell. International standards used by manufacturers of medical devices do not fully consider the environment in which the equipment is used. NHS staff are not always given guidance on how to use specific medical devices in the context of their varying environments, and how this may affect patient safety. The inability to access the Palliative Care Formulary (a best practice guide for medication prescribers), as a free resource, may have an impact on patient safety. This can be both in the palliative care specialism and across the wider healthcare system. Safety recommendations HSSIB recommends that the British Standards Institution engages with appropriate stakeholders to develop national human factors guidance, including consideration of usability and environment of use, for medical devices. This is to support international medical device standards and help manufacturers and healthcare staff to recognise these elements for the improvement of patient safety. HSSIB recommends that the British Standards Institution engages with international standards committees to influence the inclusion of human factors, including usability and environment of use requirements, in medical device and medical electrical equipment standards. HSSIB recommends that NHS England and the Medicines and Healthcare products Regulatory Agency work together to develop an effective mechanism for sharing medical device related incident data, including where devices function as designed. Safety observations Palliative care providers can improve patient safety by reviewing their ambulatory infusion pumps checks to determine whether they are in line with the Palliative Care Formulary guidance and the minimum expectations of NHS England. Ambulatory infusion pump manufacturers can improve patient safety by considering new technology to develop improved methods of alerting staff to hazardous situations. Care providers can improve patient safety for inpatients who are given medication using ambulatory infusion pumps by providing safety netting advice about alerting nursing staff to alarms, appropriate places to put ambulatory infusion pumps, and the consequences of patient interaction with the device.
