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Found 48 results
  1. News Article
    Despite ongoing efforts to improve patient safety, it’s estimated that at least 1 in 20 patients still experience medical mistakes in the health care system. One of the most common categories of mistakes is medication errors, where for one reason or another, a patient is given either the wrong dose of a drug or the wrong drug altogether. In the US, these errors injure approximately 1.3 million people a year and result in one death each day, according to the World Health Organization. In response, many hospitals have introduced guardrails, ranging from colour coding schemes that make it easier to differentiate between similarly named drugs, to barcode scanners that verify that the correct medicine has been given to the correct patient. Despite these attempts, medication mistakes still occur with alarming regularity. Dr Kelly Michaelsen, an assistant professor of anaesthesiology and pain medicine at the University of Washington wondered whether emerging technologies could help. As both a medical professional and a trained engineer, it struck her that spotting an error about to be made, and alerting the anaesthesiologists in real time, should be within the capabilities of AI. “I was like, ‘This seems like something that shouldn’t be too hard for AI to do,’” she said. “Ninety-nine percent of the medications we use are these same 10-20 drugs, and so my idea was that we could train an AI to recognize them and act as a second set of eyes.” Michaelsen focused on vial swap errors, which account for around 20% of all medication mistakes. All injectable drugs come in labelled vials, which are then transferred to a labelled syringe on a medication cart in the operating room. But in some cases, someone selects the wrong vial, or the syringe is labelled incorrectly, and the patient is injected with the wrong drug. Michaelsen thought such tragedies could be prevented through “smart eyewear” — adding an AI-powered wearable camera to the protective eyeglasses worn by all staff during operations. Working with her colleagues in the University of Washington computer science department, she designed a system that can scan the immediate environment for syringe and vial labels, read them and detect whether they match up. In a study published late last year, Michaelsen reported that the device detected vial swap errors with 99.6% accuracy. All that’s left is to decide the best way for warning messages to be relayed and it could be ready for real-world use, pending Food and Drug Administration clearance. Read full story Source: NBC News, 25 May 2025
  2. News Article
    Patients who take the common blood pressure medicine Lercanidipine HCI 20mg tablets (lercanidipine hydrochloride) from the manufacturer Recordati Pharmaceuticals Limited, should, as a precautionary measure, urgently check if they have the batch number MD4L07 with an expiry date of 01/2028 on any packs they have at home. The batch number is printed on the foil of the blister strips. This follows an error in the strength of the product printed on some of the sides of the pack. The error is limited to one batch of the medicine only. The packs are incorrectly labelled as 10mg on some sides of the pack when they are 20mg tablets. The correct strength (20mg) is printed on the top of the carton and on the blister strips. An alert has been issued by the Medicines and Healthcare products Regulatory Agency (MHRA). Patients prescribed 10mg tablets and have received tablets with this batch number should contact their pharmacist or GP immediately. If the GP or pharmacist cannot be reached, patients should call NHS 111 for advice on continuing their medication. Read full story Source: MHRA, 17 April 2025
  3. Content Article
    Recordati Pharmaceuticals Limited has informed the MHRA of an error in the strength of the product printed on some of the faces (sides) of the product carton. The error is limited to one batch of Lercanidipine HCl 20mg Tablets. The packs are incorrectly labelled as 10mg on some sides of the product carton when they are 20mg tablets. Advice for Healthcare Professionals: Stop supplying the above batch immediately. Quarantine all stock and return it to your supplier using your supplier’s approved process. This medicine is being recalled as a precautionary measure. Pharmacists who have been supplied this batch and suspect they have dispensed the tablets to patients should contact the patient immediately to make them aware of this error. Please see ‘advice for patients’ section below. Advice for Patients: Patients who have been prescribed 10 mg tablets and have received tablets with this batch number (printed on the foil of the blister strips) should contact your pharmacist or GP immediately. In the event that the GP or pharmacist cannot be reached, please call NHS 111 for advice on continuing your medication. In the event you cannot speak to a healthcare professional before you are due to take your next dose: verify the strength of the tablets is 20 mg from the information on the foil of the blister strips remove one tablet from the blister as normal locate the break line on the tablet snap the tablet in half across the break line and take half of the tablet. This is permitted for the 20mg tablets and is in line with information included in the patient information leaflet (where it states ‘The tablet can be divided into equal doses’). Patients who have been prescribed 20 mg tablets should verify the strength of the tablets by checking the information on the foil of the blister strips prior to taking the tablet. Continue to take the tablets as prescribed by your doctor. Do not stop taking your medicine without consulting your healthcare provider. Patients who are concerned about the strength of the medication they have received should check it with their dispensing pharmacy. Patients concerned they may have accidentally taken a higher dose of the medication than they were prescribed should seek medical attention. Patients who experience adverse reactions or have any questions about the medication should seek medical attention. Any suspected adverse reactions should also be reported via the MHRA Yellow Card scheme. Additional information: For all medical information enquiries and information on this product, please email [email protected], or telephone +353 (0)87 6245669.
  4. News Article
    The UK High Street pharmacy chain Boots is asking customers to return packs of 500-milligram paracetamol tablets because a labelling error incorrectly states they are a different painkiller, aspirin. More than 110,000 packs, with the batch number 241005 and expiry date "12/2029" on the bottom, are affected. Customers can receive a full refund without a receipt. Boots and the supplier, Aspar Pharmaceuticals Limited, have begun a full investigation. The outer cardboard packaging is correctly labelled: "Paracetamol 500mg Tablets" but the inner foil blister pack of pills instead reads: "Aspirin 300mg Dispersable Tablets". The affected packs should not be used or kept, even if the error is known, as this could lead to an incorrect dose. Dr Stephanie Millican, from the Medicines and Healthcare Products Regulatory Agency (MHRA), said: "Patient safety is always our priority. "It is vitally important that you check the packaging of your Boots Paracetamol 500mg Tablets 16s - and if the batch number is 241005, you should stop using the product and return it to a Boots store for a full refund. "If you are unsure which pack you have purchased or have taken Boots Paracetamol 500mg Tablets and experienced any side effects, seek advice from a healthcare professional. "Please report any suspected adverse reactions via the MHRA's Yellow Card scheme. "If you have any questions or require further advice, please seek advice from your pharmacist or other relevant healthcare professional." Read full story Source: BBC News, 4 March 2025
  5. Gallery Image
    Fentanyl, a synthetic opioid, and naloxone, a medication used to reverse or reduce the effects of opioids, both in very similar bottles and packaging. Shared originally on Twitter by @sassistheword
  6. Gallery Image
    Shared with hub by Dr Abigail Clark-Morgan: Images shared of our stocked noradrenaline ampules and tranexamic acid – these have been mixed up and we are looking to stock alternative volumes of noradrenaline to reduce the likelihood of confusion. The incident also highlighted the importance of checking all the ampules drawn up, drawing up your own medications at the point of administration and effective second checking. Part of our immediate response was to label the noradrenaline ampules to make them more obviously different (the purple ampules pictured below).

    © Healthcare UK

  7. Gallery Image
    Bupivacaine solution, a medication used to decrease feeling in a specific area, alongside sodium chloride used as a saline solution. What could go wrong?! Another example of almost identical packaging/labelling.
  8. Gallery Image
    Shared from Twitter: What could go wrong? Same size, same colourings … Time for distinct and standardised size/colouring of paralytic agents?
  9. Gallery Image
    Do we need a magnifying glass in every anaesthetic room? Only a matter of time until something bad happens...
  10. Gallery Image
    Levobupivacaine is a local anaesthetic. Labelling very similar to the Sodium chloride.
  11. Gallery Image
    Three very different solutions for injection - magnesium sulfate, water, sodium chloride - so why is the labelling so similar?
  12. Gallery Image
    These two solutions look very similar. One is paracetamol, the other Sodium Chloride. Example of packaging/labelling contributing to adverse events.
  13. Gallery Image
    A patient bought wrong aspirin from pharmacy and accidentally overdosed. Easily done with such similar packaging.
  14. Content Article
    Medication 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
  15. Content Article
    A service providing bilingual medication information is helping to reduce healthcare inequalities and medical errors. Pharmacies across London are benefitting from the support of Written Medicine; a service providing bilingual dispensing labels in patients’ language of choice. Founded in 2012, Written Medicine’s software is used by pharmacies and hospitals to translate and print medication information, instructions and warnings. Drawn from a dataset of 3,500 phrases, printed labels are available in fifteen different languages. The bi-lingual labels are supporting patients to take ownership of their treatment; giving them a better understanding of how to take their prescribed medication. The solution is helping to reduce errors, improve medication adherence and enhance patient safety and experience. London North West University Healthcare NHS Trust (LNWH) has been using Written Medicine since 2016, starting from their outpatient pharmacy in Ealing Hospital. The Trust serves an ethnically and linguistically diverse demographic across North West London, which requires interpreting services in over 40 languages, mostly from South Asia, Middle East and Eastern Europe. An audit to assess the quality and impact of the bilingual labelling service at LNWH report in 2019 stated, “post-service questionnaire revealed all patients would like the continuation of the service by their community pharmacies demonstrating the impact it has had in patient empowerment and adherence.”. Poureya Aghakhani, Principal Pharmacist at Ealing Hospital, part of LNWH said, “Patients who are unable to speak English are less likely to understand their doctors, pharmacists and written instructions. This can stop them from taking their medication or may result in them taking it in an unhelpful or dangerous way. “Giving patients information in a language they understand increases awareness around how and when medication should be taken. It empowers individuals to take ownership of their treatment, improving how they manage their conditions and reduces their risk of harm."
  16. Content Article
    Medication errors are a leading cause of patient harm globally. WHO launched the Global Patient Safety Challenge: Medication Without Harm, with the objective of preventing severe medication related patient harm globally. This publication is one of the documents in the WHO Technical Series on “Medication Safety Solutions” that the WHO is publishing, to address important aspects pertaining to medication safety. Look-alike, sound-alike (LASA) medicines are a well-recognised cause of medication errors that are due to orthographic (look-alike) and phonetic (sound-alike) similarities between medicines, which can be confusing. Look-alike medicines appear visually the same with respect to packaging, shape, colour and/or size, while sound-alike medicines are similar in the phonetics of their names, doses and/or strengths. Confusions can occur between brand-brand, brand-generic or generic-generic names. Organisations need to prospectively design and implement strategies to identify LASA medication errors and build a robust system that intercepts them before they result in patient harm. In this publication, preventive strategies that can be implemented by healthcare professionals and organisations are presented. Further information on the hub Take a look at our Error traps gallery on the hub Medication errors related to look-alike, sound-alike drugs—How big is the problem and what progress is being made?
  17. Content Article
    This is guidance for dispensing of valproate-containing medicines in the manufacturer’s original full pack, following amendments to the Human Medicines Regulations (HMRs). These amendments currently apply in England, Scotland and Wales. This guidance should be regarded as good practice by pharmacists in Northern Ireland. The change comes into force in England, Scotland and Wales from 11 October 2023.  Valproate-containing medicines are used in epilepsy and bipolar disorder. There are known risks associated with valproate-containing medicines, including significant risks to children of mothers who took a valproate-containing medicine during pregnancy. Exposure of an unborn baby to valproate during pregnancy is associated with a high risk of congenital malformations (11%) and neurodevelopmental disorders (30–40%), which may lead to permanent disability. Following a consultation, the Government has put in place amendments to the Human Medicines Regulations 2012 (HMRs) to: require manufacturer’s original full pack dispensing of valproate-containing medicines enable pharmacists to supply up to 10% more than or less than the amount on a prescription of medicines other than those containing valproate, so that they can dispense a manufacturer’s original full pack instead of splitting the pack, known as original pack dispensing (OPD). This guidance provides information on the reasons for the change to dispensing of valproate-containing medicines (as above), and outlines what pharmacists need to do differently.
  18. News Article
    Valproate-containing medicines will be dispensed in the manufacturer’s original full pack, following changes in regulations coming into effect on Wednesday 11 October 2023. The Medicines and Healthcare products Regulatory Agency (MHRA) has published new guidance for dispensers to support this change. Following a government consultation, this change to legislation has been made to ensure that patients always receive specific safety warnings and pictograms, including a patient card and the Patient Information Leaflet, which are contained in the manufacturer’s original full pack. These materials form a key part of the safety messaging and alert patients to the risks to the unborn baby if valproate-containing medicines are used in pregnancy. The changes follow a consultation on original pack dispensing and supply of medicines containing sodium valproate led by the Department of Health and Social Care (DHSC), in which there was overwhelming support for the introduction of the new measures, to further support safety of valproate-containing medicines. Minister for Public Health, Maria Caulfield, said: “This safety information will help patients stay informed about risks of valproate, and I encourage all dispensers of valproate to consult the new guidance carefully. “This continues our commitment to listening and learning from the experiences of people impacted by valproate and their families and using what we hear to improve patient safety.” Read full story Source: MHRA, 11 October 2023
  19. Content Article
    The existence of confusing drug names is one of the most common causes of medication error and is of concern worldwide. With tens of thousands of drugs currently on the market, the potential for error due to confusing drug names is significant. This includes nonproprietary names and proprietary (brand or trade-marked) names. Many drug names look or sound like other drug names. Contributing to this confusion are illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labelling, similar clinical use, similar strengths, dosage forms, frequency of administration, and the failure of manufacturers and regulatory authorities to recognise the potential for error and to conduct rigorous risk assessments for nonproprietary and brand names, prior to approving new product names This article from the WHO Collaborating Centre for Patient Safety Solutions looks at the issues and suggests actions.
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