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Showing results for tags 'Medication'.
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News ArticleThe National Pharmacy Association (NPA) has asked community pharmacies to report all patient safety incidents despite growing work pressure due to a persisting virus pandemic. Since March, there has been a significant decrease in the number of patient safety incidents being reported, the NPA said in its medication safety update for the second quarter of 2020. Overall, there was a 44.5% decrease in the number of incidents reported during the second quarter of the year, compared to the first quarter of 2020. There was a 40.6% decrease in the number of patient safety incidents when compared to the same quarter in 2019. “This is a significant reduction in number of incidents being reported. This may be due to the increased workload and pressure on pharmacy teams due to COVID-19 pandemic, whereby pharmacy teams may not be prioritising reporting of patient safety incidents, or due to other, as yet unknown, reasons,” NPA said in its update. NPA advises community pharmacists to ensure that they report the actual degree of harm caused to the patient and not the potential harm that could have happened. The pharmacy body also suggested pharmacists should make sure that they complete a detailed outcome if an incident did lead to moderate or severe harm to the patient. This allows a thorough analysis to be undertaken by the NPA. Community pharmacists are also advised to ensure the incident form is fully completed, is accurate and includes sufficient details to allow meaningful analysis of the incident. Read full story Source: Pharmacy Business, 27 October 2020
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News ArticleA major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals. University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication. The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites. Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.” The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. Read full story (paywalled) Source: HSJ, 23 October 2020
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AHRQ Pharmacy Health Literacy Center
Patient Safety Learning posted an article in Medicine management
The tools include: Seven health literacy tools for pharmacy: Pharmacy Health Literacy Assessment Tool & User's Guide. Training Program for Pharmacy Staff on Communication. Guide on How To Create a Pill Card. Telephone Reminder Tool To Help Refill Medicines On Time. Explicit and Standardized Prescription Medicine Instructions. How to Conduct a Postdischarge Followup Phone Call Health literacy tools to improve communication for providers of medication therapy management Curricular modules for pharmacy faculty. Resources for pharmacists interested in understanding more about health literacy. Health literacy tools to improve communication for providers of medication therapy management. -
News ArticleAn independent review found that commissioners’ investigation of a young boy’s death was ‘mismanaged’, and heard allegations that the person who coordinated it was bullied over the contents. The independent review, commissioned by NHS England, has published its final report following an investigation into Bristol, North Somerset and South Gloucestershire clinical commissioning group’s LeDer review into the death of Oliver McGowan. Chaired by Fiona Ritchie, the independent review was commissioned last year after evidence emerged that the CCG had rewritten earlier findings of the review, removing suggestions his death at North Bristol Trust in 2016 was avoidable. Oliver died in November 2016 after being given anti-psychotic medication against his own and his parents’ wishes and despite medical records showing he had an intolerance to anti-psychotics. He developed severe brain swelling because of the drugs and died.A local LeDer review — part of a programme aimed at improving care based on deaths among people with learning disabilities — was launched in 2017, seven months after his death, by the CCG (then operating as three separate organisations), then published in 2018. In 2018, a coroner concluded Oliver’s care prior to his death was “appropriate” and made no recommendations. His death is also currently the subject of a police investigation. The lead reviewer (Ms A) stated in her panel interview that during the time she was undertaking this LeDeR she had felt bullied, overworked and overly stressed by the demands placed on her by the various correspondences with solicitors and her line management. The fact that Ms A believed she was isolated and unsupported during this review illustrates evident failures in the CCG assurance and management processes at the time. In a final report by the subsequent independent review, published today, the panel led by Ms Ritchie “unanimously” agreed Oliver’s death was “potentially avoidable”. Read full story (paywalled) Source HSJ, 20 October 2020
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Content ArticleThis resource includes: What is medicines management? The right medicine for the right patient and the right time Becoming an independent prescriber Competencies and maintaining competence Specialist prescribing Delegation Unregistered staff and social care Administration Prescribing and administration Transcribing Nursing associates and medicines management Summary of available guidance
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EU Regions Driving Medicine Safety Event
Patient Safety Learning posted a calendar event in Community Calendar
untilA digital event showcasing how Northern Ireland is collaborating throughout Europe to improve medicines use. To register email: moic@northerntrust.hscni.net -
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Breastfeeding and medication
PatientSafetyLearning Team posted an article in Women's health
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EventuntilPatient Safety: Embracing technology in a rapidly evolving healthcare environment to reduce medication errors. In England 237 million mistakes occur at some point in the medication process. By embracing technology that already exists, we may actually hold the key to being able to significantly reduce this figure. Join Andrea Jenkyns MP, pharmacy and nursing thought leaders and patient safety representatives for an interactive discussion on embracing technology to reduce medication errors. The timing of this event is particularly significant as World Patient Safety Day takes place the following day and so these issues should be at the forefront of policy makers minds. Confirmed panelists include: Prof. Liz Kay, Former Director of Pharmacy at Leeds Teaching Hospitals NHS Trust Heather Randle, Lead for Medication Management at Royal College of Nursing Clive Flashman, Chief Digital Officer at Patient Safety Learning Ed Platt, Automation Director, Omnicell Registration
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Content ArticleDuring the debate there were contributions from a range of parliamentarians reflecting on the First Do No Harm report and the implementation of its recommendations in Scotland. Some points of interest from the debate included: Jeane Freeman MSP indicated the intention of the Scottish Government to implement the recommendations of the First Do No Harm report which fall within its remit and powers. Their discussion about the report's recommendation that specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh. While Jeane Freeman noted that a National Mesh Removal Service had been established in Glasgow last year, Neil Findlay MSP expressed concerns that the levels of coproduction involved in the design and delivery of this service were inadequate. Alison Johnstone MSP highlighted the particular impact of these issues on women and noted nthat the findings reflected the ways in which women are disadvantaged in accessed health and social care services. In her closing remarks Clare Haughey MSP, Minister for Mental Health, noted the intention to begin a consultation on the Scottish Government's proposal to introduce a Patient Safety Commissioner. Follow the link below for the full transcript.
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Content ArticleDuring the debate on the second reading of the Bill there were contributions from a range of parliamentarians, reflecting on how it related to the recommendations in the recently published First Do No Harm report by the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege (also known as the Cumberlege Review). Some points of interest from the debate included: Baroness Cumberlege noting concerns that "rumours are absolutely rife of a ritual burial" of the First Do No Harm report. She noted plans to create a parliamentary group called First Do No Harm to ensure the recommendations of the report were implemented. She stated her intention to put down an amendment to the Bill to include a proposal to appoint a patient safety commissioner, one of the key recommendations of the report. In his closing comments Lord Bethell, Parliamentary Under-Secretary of State (Department of Health and Social Care), noted that this amendment had support from a number of members of the House of Lords and that they had sent "a clear message to the Government and the public that patient safety must be paramount in how we regulate medicines and medical devices". Follow the link below for the full transcript.
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News ArticleTheresa May has urged the government to consider “redress” for the victims of a hormone pregnancy test blamed for causing serious birth defects. The former prime minister said that while Primodos victims had received an apology, “lives have suffered as a result” of the drug’s use. In an interview for a Sky News documentary, she praised campaigners who had been “beating their head against a brick wall of the state” which tried to “stop them in their tracks”. A review in 2017 found that scientific evidence did “not support a causal association” between the use of hormone pregnancy tests such as Primodos and birth defects or miscarriage. But Ms May ordered a second review in 2018, because, she said, she felt that it “wasn’t the slam-dunk answer that people said it was”. “At one point it says that they could not find a causal association between Primodos and congenital anomalies, but neither could they categorically say that there was no causal link,” she said. The second review concluded last month that there had been “avoidable harm” caused by Primodos and two other products – sodium valproate and vaginal mesh. An interview for Bitter Pill: Primodos, which will air on Sky Documentaries, Ms May said: “I think it’s important that the government looks at the whole question of redress and about how that redress can be brought up for people. Read full story Source: The Independent, 28 August 2020
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Coroner warns about poor drug reviews after patient dies from tramadol overdose
Patient Safety Learning posted a news article in News
A senior coroner has demanded action by Simon Stevens, chief executive of NHS England, to ensure that GPs monitor repeat prescriptions properly, after an 84 year old man with dementia died from an overdose of tramadol. Peter Cole, who was found collapsed at his home in Welwyn in Hertfordshire by a neighbour, had amassed a large quantity of unused prescription drugs at his house. He had numerous drugs on repeat prescription, said Geoffrey Sullivan, chief coroner for Hertfordshire. Read full story (paywalled) Source: BMJ, 5 August 2020 -
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Antibiotic Resistance & Patient Safety Portal
Claire Cox posted an article in International patient safety
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Content ArticleContent includes: Patient Safety: We’ve Come a Long Way National Patient Safety Consortium: Learning from Large-Scale CollaborationPatient Engagement in a Large-Scale Change Initiative: “As Safe as Possible, as Soon as Possible” Commentary: Three Ideas About “Post-Vention” Patient Safety Never Events: Cross-Canada Checkup Empowering Patients: 5 Questions to Ask About Your Medications Accelerating Post-Surgical Best Practices Using Enhanced Recovery After Surgery Patient Safety Culture Bundle for CEOs and Senior Leaders Commentary: We Must Look at Multiple Perspectives Homecare Safety Virtual Quality Improvement Collaboratives Commentary: Patient Safety in the Home Measuring and Monitoring Healthcare-Associated Infections: A Canadian Collaboration to Better Understand the Magnitude of the Problem Patient Safety: Patient Involvement Matters.
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Medication safety: "Know Check Ask"
Claire Cox posted an article in Resources for patients
