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Found 56 results
  1. 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.
  2. News Article
    Phrases such as “cutting edge,” “game changing,” and “ground breaking” have no place in the description of new drugs by the government and NHS agencies, a therapeutics specialist and GP has warned. James Cave, editor in chief of the Drug and Therapeutics Bulletin (DTB), said in an editorial1 that the degree of hyperbole and omission of important information in government press releases and media statements “leaves patients and healthcare professionals with a limited and unbalanced view of a medicine.” In a letter to the heads of NHS England, the National Institute for Health and Care Excellence (NICE), and the Medicines and Healthcare Products Regulatory Agency (MHRA) he referred to a loss of objectivity in statements about new drugs over the past few years. Rather, some statements contained “a degree of hyperbole that might be more associated with an advertising agency.” Read full story (paywalled) Source: BMJ, 28 September 2022
  3. Content Article
    2022 ISSUE 1 - Anti-rejection medications: Analysis of reported errors ISSUE 2 - Mitigating Risk for Medication Errors Involving Paxlovid ISSUE 3- Heightened Risk of Methotrexate Toxicity in End-Stage Renal Disease ISSUE 4 - ALERT: Multipronged Strategy Required to Manage Shortage of Sterile Water for Injection ISSUE 5 - Pediatric Medication Errors in the Community: A Multi-Incident Analysis ISSUE 6 - ALERT: Substitution Error with Tranexamic Acid during Spinal Anesthesia ISSUE 7 - Emergency Care Plans Can Save Lives ISSUE 8 - ALERT: Infusion Errors Leading to Fatal Overdoses of N-Acetylcysteine ISSUE 9 - Safer Labelling of Repackaged Active Pharmaceutical Ingredients for Pharmacy Compounding ISSUE 10 - Optimizing Medication Safety in Virtual Primary Care
  4. Content Article
    Saturday 17 September 2022 marks the fourth annual World Patient Safety Day. This event was established by World Health Organization (WHO) as a day to call for global solidarity and concerted action to improve patient safety. It aims to bring together patients, families, carers, healthcare professionals and policymakers to show their commitment to patient safety. Avoidable harm in health and social care What is patient safety? Simply put, patient safety is concerned with avoiding unintended harm to people during their care and treatment. WHO describes it as follows: “Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur.”[1] Modern health and social care is incredibly complex and complicated, meaning that there are range of different ways in which unintended avoidable harm can occur. Each year, millions of patients suffer injuries or die because of this, with WHO stating that unsafe care is likely one of the top ten leading causes of death and disability worldwide.[2] In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed.[3] This comes at a huge financial cost, with the Organisation for Economic Co-operation and Development (OECD) estimating that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending.[4] Avoidable harm also has an untold physical and emotional impact on those affected, resulting in a loss of trust in the healthcare systems by patients, and frustration and a loss of morale among healthcare professionals at not being able to provide the best possible care. Need for transformation in our approach to patient safety The impact of avoidable harm and the need to make significant improvements to patient safety is well-established in health and social care. However, despite this knowledge, and the hard work of many people involved in the sector, avoidable harm continues to persist at an unacceptable rate. At Patient Safety Learning we believe that the persistence of avoidable harm is the result of our failure to address the complex systemic causes that underpin it. We argue that there needs to be a transformation in our approach to this problem. Key to this is ensuring patient safety is treated as core to the purpose of health and social care, not simply as one of several competing strategic priorities to be traded off against each other. In our report, A Blueprint for Action, underpinned by systemic analysis and evidence, we identify six foundations of safe care for patients and these practical actions to address them:[5] Shared Learning – organisations should set and deliver goals for learning, report on progress and share their insights widely for action. It is not enough to say, ‘we’ve learned from incidents of unsafe care’, we need to see action for improvement and impact. Leadership – we emphasise the importance of overarching leadership and governance for patient safety. This is not just about governance; it is about behaviours and commitment too. Professionalising patient safety – organisations need to set and deliver high standards for patient safety. These need to be used by regulators to inform their assessment of whether organisations are doing enough to prevent avoidable harm and assess whether they are safe. Patient Engagement – to ensure patients are valued and engaged in patient safety, at the point of care, if things go wrong and for redesigning health care for safety. Data and Insight – better measurement and reporting of patient safety performance, both quantitative as well as qualitative. Just Culture – all organisations should publish goals and deliver programmes to eliminate blame and fear, introduce or deepen a Just Culture, and measure and report progress. Medication safety When considering avoidable harm in health and social care, unsafe medication practices and medication-related harm are one of the leading causes of this, with WHO noting that: Medication harm accounts for 50% of the overall preventable harm in medical care.[6] $42 billion (US dollars) of global total health expenditure worldwide can be avoided if medication errors are prevented.[6] This year’s World Patient Safety Day focuses on the issue of medication safety and the need to build on the existing WHO Global Patient Safety Challenge: Medication Without Harm. The campaign emphasises the need to adopt a systems approach to this challenge, promote medication safety practices to prevent medication errors and reduce medication-related harm.[7] The Global Challenge was launched in 2017 with a goal “to gain worldwide commitment and action to reduce severe, avoidable medication-related harm by 50% in the next five years”.[8] As we reach the end of this period, Patient Safety Learning believes that it is important now that countries report publicly on their progress against this, enabling WHO evaluate both positive developments and where improvement is required. Medication safety covers a huge range of different issues and concerns and here we will highlight a few examples from Patient Safety Learning’s work and topical issues highlighted on our award-winning patient safety platform, the hub. Listening and responding to patient concerns A key barrier to improving patient safety around medication concerns the dismissal of concerns raised by patients when harmful side effects occur. A recent example of this in the UK was highlighted by the Independent Medicines and Medical Devices Safety (IMMDS) Review, which investigated a truly shocking degree of avoidable harm to patients over a period of decades relating to two medications, hormone pregnancy tests and sodium valproate, and pelvic mesh implants. The Review exposed a range of medication safety concerns, including a lack of informed consent, failures by incident reporting schemes to recognise safety concerns and a failure to support patients after unsafe care, stating: “As we have seen and heard, all too often patient reports of harm are either not listened to or are dismissed as subjective, unscientific and anecdotal.”[9] Key to highlighting these issues, and pushing for change, was the tenacious work of campaigning patients and families affected by this, as described in a recent interview on the hub with Marie Lyon, Chair of the Association for Children Damaged by Hormone Pregnancy Tests. In response to this Review there will soon be new Patient Safety Commissioner roles created in England and Scotland. While these roles can provide a new voice and hopefully influence for patients in relation to medication safety in the UK, this must also be accompanied by a shift in attitudes and approach towards patients’ involvement in care and their safety. Packaging and processes The WHO Medication Without Harm initiative recognises that one of the key challenges to the safe administration of medication often lies in complex and unclear processes which can result in mistakes that lead to patient harm. An example of this is when packaging and labelling of medications creates error traps, situations that could lead into avoidable harm in a busy, pressurised health and social care workplace, such as different medications being stored together in almost identical packaging. We have been collating different examples from healthcare professionals of look-alike medicines on our error traps gallery on the hub. We also need to look at how we can reduce the complexity around medication prescription and administration to reduce the risk of mistakes that lead to harm. Laurence Goldberg highlights examples of this such as regards to ready-to-administer injections and unit dose drug distribution in a new blog featured on the hub. Engaging with patients in the medication process Building on our previous comments around listening to patient concerns, actively involving them in their care is also a key issue in ensuring medication safety. In our recent analysis of investigation reports by the Healthcare Safety Investigation Branch (HSIB) in England we have seen numerous examples where family members of patients have played a key role in spotting and alerting healthcare professionals to safety concerns. Cases of this vary from appropriate insulin administration to safety concerns around the prescription of liquid morphine. WHO have developed a helpful tool to support patient involvement in this area, 5 Moments for Medication Safety. This helps to highlight how the risk of harm can be reduced by involving patients at different stages of the medication process. The implementation gap As with many other issues in patient safety, a key challenge in reducing medication-related harm remains overcoming the ’implementation gap‘, the difference between what we know improves patient safety and what is done in practice. In our report from earlier this year, Mind the implementation gap, we highlighted how too often we fail to translate patient safety insights and learning into practical improvements, due to a lack of systems for sharing learning, absence of oversight and unclear patient safety leadership. Returning to the IMMDS Review we can see a clear example of the implementation gap in relation to sodium valproate. Despite a clear body of evidence about the risks, birth defects or development delays associated with taking this medication during pregnancy, the safety actions identified by the review and ongoing campaigning by groups such as the Independent Fetal Anti-Convulsant Trust, pregnant women and birthing people in the UK continue to be prescribed this medication. In addition, they do not always receive the appropriate advice on the risks associated with this. There is much that still needs to be done in medication safety to improve our approach to not only sharing good practice but ensuring that this is implemented widely and consistently. Share your experience with us Do you have an experience to share around medication safety as a patient, carer or family member? Or perhaps you are a healthcare professional looking to share your frontline insights to help improve safety? Join the conversation by signing up to our patient safety platform the hub and sharing your views, or get in touch with us by emailing content@pslhub.org. Related reading You can find a wide range of medication safety related articles on issues such as medication administration, labelling, patient medication stories and medicine management on the medication section of our patient safety platform the hub. We’ve also published several articles on this subject specifically for World Patient Safety Day this year which you can find below: Patient Safety Spotlight interview with Angela Carrington, Lead Pharmacist for Medication Safety in Northern Ireland Reducing medication errors: a blog from Laurence Goldberg for World Patient Safety Day Top picks for World Patient Safety Day 2022: Medication safety in hospitals Top picks for World Patient Safety Day 2022: Patient engagement for medication safety Top picks for World Patient Safety Day 2022: Medication safety in social care References WHO, Patient safety – About us, Last Accessed 13 September 2022. WHO, 10 facts on patient safety, 26 August 2019. NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. OECD, Patient Safety, Last Accessed 20 October 2021. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. WHO, World Patient Safety Day 2022, Last Accessed 14 September 2022. WHO, Medication Without Harm, Last Accessed 14 September 2022. WHO, Medication Without Harm: WHO Global Patient Safety Challenge, 2017. The IMMDS Review, First Do No Harm, 9 July 2020
  5. Content Article
    Key messages As many as one in ten hospitalisations in OECD countries may be caused by medication related harm. One in five inpatients experience medication-related harms during hospitalisation. Over $54 billion (US Dollars) is spent on medication-related harm in OECD countries (cost from avoidable admissions due to medication related harms plus added length of stay due to preventable hospital-acquired medication-related harms). This report is divided into four main sections: 1. Medication-related harms and errors are not rare events and have significant economic impact This section considers the human impact and economic costs of medication safety events and includes the following points: There has been limited progress in improving medication safety due to a number of converging factors. The occurrence of medication errors can lead to an erroneous feedback loop - compounding harms. Non-pharmacological treatment alternatives are underused despite their demonstrated effectiveness to treat several chronic conditions. Increasing use of pharmacological treatment for chronic conditions is a contributing factor to potentially dangerous polypharmacy. Some patient groups are particularly at risk of medication-related harm, particularly older patients, patients taking anti-psychotic medications and people living with dementia. The prevalence of inappropriate prescribing is substantial, and possibly increasing. In the OECD they estimate that there are over six million hospital admissions annually are the result of medication-related harm. Each year, more than one million hospitalised patients in OECD countries experience a preventable medication-related harm in hospital. 2. Reducing inappropriate prescribing and improving the rational use of medicines This section considers the importance of the rational use of medicines - ensuring the right medicine at the right dose and duration for the right patient. It includes the following points: The most common form of irrational use of medicines is overuse, such as inappropriate polypharmacy. The inappropriate use of antibiotics has led to growing crisis of antimicrobial resistance. Underuse of medications does not receive much attention, however it also contributes significantly to global morbidity and mortality. Regulatory and economic interventions can improve medication utilisation and reduce costs but require robust evaluation alongside implementation. 3. Improving medication safety throughout the care pathway This section considers different national strategies to improve medication safety and includes: An overview of selected national medication safety regulations or strategies. Discussion of the role of pharmacovigilance and drug utilisation reviews. Consideration of the status and adoption of digitalisation and medication patient safety initiatives in different OECD countries. 4. Building medication safety into the Covid-19 recovery This section considering the opportunities as countries look to adapt their health systems to build medication safety into their Covid-19 response and recovery activities. It includes the following points: The dynamics created by Covid-19 can be used to accelerate change. Importance of improving the functionality of data for monitoring medication safety in real-time. Need to use good patient safety governance and transparency to build public trust. Leadership commitment is required to establishing and maintaining a safe, people-centred environment that enables reporting to medication safety surveillance systems. Investments should continue to build systems that capture patient experience of medication-related harms and medication side-effects. There should be greater support for people-centred care systems and shared-decision making. Other OECD patient safety reports available on the hub Developing international benchmarks of patient safety culture in hospital (19 January 2022) The economics of patient safety: Strengthening a value-based approach to reducing patient harm at national level (June 2017) The economics of patient safety in primary and ambulatory care: Flying blind (November 2018) Culture as a cure: Assessments of patient safety culture in OECD countries (2 June 2020) The economics of patient safety part III: Long-term care (17 September 2020) The economics of patient safety: From analysis to action (21 October 2020) The economics of patient safety part IV: Safety in the workplace (10 September 2021)
  6. Content Article
    The mission of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is to maximise the safe use of medications and to increase awareness of medication errors through open communication, increased reporting and promotion of medication error prevention strategies. Goals Stimulate the development and use of reporting and evaluation systems by individual health care organisations. Stimulate reporting to a national system for review, analysis, and development of recommendations to reduce and ultimately prevent medication errors. Examine and evaluate the causes of medication errors. Increase awareness of medication errors and methods of prevention throughout the health care system. Recommend strategies for system modifications, practice standards and guidelines, and changes in packaging and labelling. Objectives Promote reporting, discussion and communication about safe medication use, medication errors and error-prone processes, and error-prevention strategies. Develop and broadly disseminate NCC MERP's recommendations and other work products related to reporting, understanding, and prevention of medication errors. Collaborate with other interested stakeholders to address special topics related to medication errors and patient safety initiatives. Strategies Medication error reporting Heighten awareness of reporting systems available to or within health care organisations. Stimulate and encourage reporting and sharing of medication errors both nationally and locally. Develop standardization of classification systems for the collection of medication error reports so that databases will reflect reports and categorization systems. Encourage systems and provide targeted feedback so that appropriate prevention strategies can be developed and implemented in facilities. Medication error understanding Assess current knowledge of medication errors through ongoing efforts (for example, literature searches) to gather data associated with the scope of problems, types of errors, causes and sources of errors, and clinical and financial impact on patients and the healthcare delivery system. Identify gaps in research that hinder the understanding of medication errors. Promote research to expand knowledge regarding medication errors, their causes, and the effectiveness of interventions Medication error prevention Encourage standardisation of processes to prevent error-prone aspects of drug procurement, prescribing, dispensing, administration, disposal. Encourage shared accountability and systems-based solutions to enhance the safety of medication use and to minimise the potential for human error. Promote/encourage the safe use and understanding of technology in the prevention of medication errors. Increase awareness of the need for distinctive packaging, labeling, and nomenclature of products associated with actual or potential medication errors. Educate consumers and patients regarding strategies to prevent medication errors for both prescription and nonprescription medications. Educate health care professionals about causes of medication errors and strategies for prevention.
  7. Event
    To mark the annual World Patient Safety Day, three organisations - COHSASA of South Africa, AfiHQSA of Ghana and C-CARE (IHK) of Uganda - are collaborating to bring you the latest thinking across Africa regarding 'Medication without harm', the theme for WHO's Third Global Patient Safety Challenge. The Challenge aims to reduce the global burden of iatrogenic medication-related harm by 50% within five years. Join us to hear new ideas, visions and solutions to address medication-related adverse events which cause untold death and suffering around the world. Register for the meeting FINAL INVITE FOR WPSD WEBINAR.pdf
  8. Content Article
    Did you know? Key causes of anti-infective medication error claims: Failure to check allergy status. Failure to cross-check the ingredients of a medication against allergy status. Failure to adjust dose of medication to the patient’s weight. Failure to adjust dose of medication according to renal function. What can you do? When prescribing antibiotics, refer to the British National Formulary (BNF) for guidance on adjusting dosages according to patient weight, kidney function and the frequency of monitoring. Refer to the traffc light system for antibiotics and penicillin allergy. Ensure that the weight of a patient is regularly checked and adjust drug doses accordingly. • Check the allergy status of the patient at each point of the medication process. Review local guidelines to ensure they incorporate national guidance and support clinicians to prescribe, administer and monitor the effects of anti-infectives appropriately. Examples of relevant national guidance include NICE quality standards on on antimicrobial stewardship and sepsis. Access the NICE guidelines on acute kidney injury to fnd information and advice on the prevention, detection, and management of acute kidney injury. Review your organisation’s claims history regarding medication errors and ensure that learning is shared with clinicians.
  9. News Article
    Only a quarter of patients on valproate, who do not have appropriate contraception, are being referred by their pharmacist to their GP or a specialist about the issue, an audit carried out by NHS England has found. A report on the 2019/2020 Pharmacy Quality Scheme Valproate Audit — which was carried out in community pharmacies across England — published on 11 August 2022, has indicated that the Medicines and Healthcare products Regulatory Agency’s (MHRA’s) safety requirements for use of valproate in women and girls of childbearing age, and trans men who are biologically able to be pregnant, are “still not being fully met”. Since 2018, the MHRA has advised that valproate, a treatment for epilepsy and bipolar disorder, must not be used in anyone of childbearing potential, unless a Pregnancy Prevention Plan (PPP) is in place. As part of a PPP, pharmacists are required to remind patients of the risks of taking sodium valproate in pregnancy and the need for highly effective contraception; ensure patients have been given the patient guide; and remind patients of the need for an annual specialist review. However, the audit, which was conducted by 10,293 community pharmacies in England, including responses from 12,068 patients and patient representatives, found that pharmacists were not referring or signposting “a sizeable minority”, who appeared to be without appropriate contraception, back to the prescriber. The report said that community pharmacists should refer “all people aged 12–55 who are biologically able to be pregnant and have not had their valproate medication reviewed within the last 12 months to their GP or specialist, as well as to local contraception services as appropriate”. For patients not referred to their GP or specialist, the report said that the pharmacist should be able to confirm that the patient is fully informed, understands the risks of not using highly effective contraception and knows who to contact if their circumstances change. Read full story Source: The Pharmaceutical Journal, 12 August 2022
  10. Gallery Image
    Similar looking boxes, but different drugs, stored together on the shelf. Easy to pick the wrong one up.
  11. Content Article
    Arterial lines are routinely fitted for severely ill patients in critical care and are flushed with a solution to maintain patency, and ensure that blood does not clot in the line. Saline is recommended as the flush solution for arterial lines. There is a known patient safety risk in connection with this where glucose solutions being inadvertently and incorrectly used to flush arterial lines. This has led to inaccuracies in blood glucose measurements, which resulted in unnecessary administration of insulin and subsequent cases of hypoglycaemia, some of which have been fatal. Findings The key findings from the investigation include: The physical layout and design of the clinical and storage areas will influence how reliably staff are able to select and collect similar-looking equipment and medication. The labelling of bags of fluids, similar looking medications and manufacturers’ packaging reduce the reliability of selecting the correct flush fluid in the context of a critical care unit with time pressures and high workloads. The procurement and design of arterial transducer line equipment, the pressure infusion bags and transducer, do not assist in the identification of the incorrect flush fluid or prevent contamination from the flush fluid of a blood sample taken from the arterial line. Alternative equipment, for example transparent pressure infusion bags and closed arterial transducer lines, are currently available to the NHS. These may reduce the risk but are not routinely in use. Challenges in the provision of a consistent suitable workforce and high workloads have a detrimental effect on the safety controls currently relied upon to avoid or identify the risk of using the wrong flush fluid. Safety checks and training lack resilience to organisational pressures regularly experienced within critical care units. There can be a delay in identifying the contamination with glucose of an arterial line blood sample due to a normalisation and acceptance that critically ill patients may have altered blood glucose levels and require insulin treatment, and a perceived low risk associated with the use of a flush fluid. The design of systems to record and monitor information relevant to the arterial transducer line system and blood glucose levels do not easily alert staff to the potential use of the wrong flush fluid. Recommendations issued over the last 14 years by national safety bodies and professional healthcare organisations to address the safety of blood sampling associated with arterial lines have not been effectively implemented. Safety recommendations The report makes the following safety recommendations: HSIB recommends that the Medicines and Healthcare products Regulatory Agency [Head of Metabolic Disorders and Renal Systems] engages with other national regulators and relevant stakeholders to develop design guidance on labelling and packaging specific to fluids to reduce selection errors. HSIB recommends that the Medicines and Healthcare products Regulatory Agency [Head of Metabolic Disorders and Renal Systems] reviews and acts on the available evidence to regulate for the use of pressure infusion bags that allow fluid labels to be read when inflated. HSIB recommends that the Medicines and Healthcare products Regulatory Agency [Head of Metabolic Disorders and Renal Systems] communicates to all relevant stakeholders and acts on the available evidence concerning the management of the risks associated with arterial transducer line sets. HSIB recommends that the Department of Health and Social Care [Director of Medical Technology], once post-market surveillance data is available, involves relevant stakeholders including the Association of Anaesthetists’ review and determine appropriate actions that could be taken to further mitigate the risk of blood sample contamination by the flush fluid when using arterial transducer line systems. HSIB recommends that the Association of Anaesthetists [President] works with relevant professional organisations to revise existing national guidance to manage the risks of contamination by the flush fluid when using an arterial line to take a blood sample. HSIB recommends that the Care Quality Commission [Chief Executive] reviews the recommendations from the Association of Anaesthetists on how to manage the risks of contamination by the flush fluid when using an arterial transducer line and determines any appropriate actions for the oversight of governance and assurance arrangements within NHS providers following.
  12. News Article
    A shortage of some medicines is putting patients at risk, pharmacists have warned. A poll of 1,562 UK pharmacists for the Pharmaceutical Journal found more than half (54%) believed patients had been put at risk in the past six months due to shortages. A number of patients have been facing difficulties accessing some medicines in recent months, sometimes having to go to multiple pharmacies to find their prescription or needing to go back to their GP to be prescribed an alternative. Since June, the government has issued a number of "medicine supply notifications", which highlight shortages. Some of these include: pain relief drugs used in childbirth; mouth ulcer medication; migraine treatment; an antihistamine; a drug used by prostate cancer and endomitosis patients; an antipsychotic drug used among bipolar disorder and schizophrenia patients; a type of inhaler and a certain brand of insulin. Read full story Source Sky News, 11August 2022
  13. Community Post
    See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
  14. Content Article
    ADRe is designed for use by nursing staff (NVQ level 3-5 or above), the professionals closest to patients. By using ADRe complex information on drugs is combined into a checklist providing advice on common problems. This helps nurses recognise and act on adverse drug reaction, including pain, dental pain, aggression, peptic ulcers, and sedation. In doing so, it greatly enhances the administration of medicines, and by capturing this individualised picture of the patients’ health and well-being prompts prescribers to refine dosages. ADRe is very simple to use: Nurses use the Profile to check and record problems that might be related to prescribed medicine. Nurses solve some problems, e.g. dental pain, dehydration, by referrals or paying closer attention to intake. Nurses share the completed ADRe Profile with prescribers (GPs or specialists), who decide prescriptions and doses. Repeating the Profile one month later ensures no new issues have arisen. You can request a copy of the full tool, or even try out part of our digital app by registering.
  15. Content Article
    Key recommendations Democratising access Governments should: Fund annual medicine reviews to help people with chronic conditions with decision making and any identified gaps in care, and report on the number of medicine reviews conducted every year across different demographic groups. Prevent co-payments from causing a barrier to adherence, as evidence shows they can hinder people from taking prescribed medication. Invest in HCP training programmes on behaviour change to supply workers with the requisite skills and knowledge to support adherence to medication regimes and lifestyle behaviour programmes. Universities should: Ensure that undergraduate curricula for all HCPs include an adherence topic that communicates the importance of adherence for the health outcomes of individuals, and helps HCPs to implement effective behaviour change methods. Inspiring and engaging Governments should: Promote and prioritise adherence as an effective disease management tool, by including it in national chronic disease strategies; for example, those for CVD, osteoporosis and diabetes. Set metrics for acceptable adherence rates, and measure and report on adherence rates for chronic conditions, including CVD, diabetes and osteoporosis, at a national (or subnational) level. Establish behavioural insight teams with a focus on health, and research the effect of using different incentives to encourage people with chronic conditions to adhere to medications and lifestyle changes. Expand the role of pharmacists, with concomitant resources and funding, to allow these professionals to support adherence, monitor for signs of non-adherence and conduct medicine reviews. WHO should: Publish annual adherence rate results, with comparisons between countries. Providers should: Use learnings from the research on the different adherence trajectories for different groups with chronic conditions to develop tailored interventions for people at greater risk of non-adherence. Explore using the COM-B model to develop interventions that support individuals to adhere to their medical directions. Better use of technology Governments should: Invest in research to test how technology, including wearables, can improve adherence. Invest in the collection and management of electronic health records, including supporting deidentified assessments of patterns of use and care. Ensure that people with chronic conditions can view their health records easily and that records incorporate information and advice to be used as a tool to help with medication adherence and management. Healthcare providers should: Build on the increased use of online consulting during the pandemic to deliver more regular virtual follow-up reviews to check medication adherence and management.
  16. News Article
    Guy’s and St Thomas’ NHS Foundation Trust will work with Omnicell to develop a European technology-enabled inventory optimisation and intelligence service which will be initially implemented across South East London Integrated Care System (ICS). This partnership will encompass all six acute hospital sites within the South East London ICS, including Guy’s & St Thomas’, Kings College Hospital NHS Foundation Trust and Lewisham & Greenwich NHS Trust. The project will have the following goals: Develop analytics and reporting tools with a goal of improving patient safety, achieving increased operational efficiency and cost efficiencies Utilize the analytics and reporting tools with a goal of achieving agreed efficiencies and cost reductions Demonstrate the impact of managing clinical supplies and medicine spend together at scale Build a service model for the ICS which can be scaled up and adopted by other hospital groups in the UK Read the full article here