Search the hub

The aim of the World Health Organization (WHO) pharmaceutical newsletter is to disseminate information on the safety and efficacy of pharmaceutical products, based on information received from networks of "drug information officers" and other sources such as specialised bulletins and journals. Download all issues from the link below. To subscribe and automatically receive the electronic version of every new issue of the WHO Pharmaceuticals Newsletter, please send an email to: [email protected] (do not enter subject or message text).

Pharmacovigilance is the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other medicine/vaccine related problem. This article, published in the journal Drug Safety, outlines how the Egypt Chapter of the International Society of Pharmacovigilance (ISoP) approached raising awareness of the importance of pharmacovigilance and reporting adverse drug reactions during MedSafetyWeek 2020.

The Medication Errors Group was established in 2017 under the leadership of Dr Brian Edwards and Professor Ian Wong.. Ensuring the safe and effective use of healthcare products is a key objective for those who work in pharmacovigilance, as well as all other stakeholders, including patients and caregivers. One key element of that is working to reduce and mitigate medication errors and other irrational use of drugs. The mission of the Medication Errors Group is To provide an opportunity for International Society of Pharmacovigilance (ISoP) members, and like-minded collaborators, to network globally in a professional and neutral environment, to share evidence and solutions that can ideally eliminate and/or at least reduce the number and severity of medication errors. This will enable continuous improvement in the use of medicines whilst supporting the interests of patients and their families, and healthcare professionals. The objectives of the Medication Errors Group are aligned with and expand on WHO Medication Safety Objectives as follows: To create opportunities for those researching and investigating medication errors to network in a friendly and mutually supportive environment and disseminate their research using good quality outlets. To support healthcare professionals and/or organizations with scientific evaluation of medication errors and how to prevent them. To promote and develop teaching and education about all aspects of medication errors including their mitigation as part of pharmacovigilance, patient safety and pharmacology curricula. To support regulatory authorities with medication errors guidance evaluation and acting as a neutral bridge with the wider pharmaceutical and healthcare sectors. To organise and/or support training and tutorials to pharmacovigilance centres to further enable their role in detecting medication errors through Individual Case Safety Reports (ICSRs) by using specific methods and tools. Insights from this enhanced detection could lead to signal detection and which may inform on new and/or targeted prevention strategies to reduce medication errors. To provide a neutral and impartial forum for all stakeholders including patients to ask questions related to medication errors and obtain answers within a reasonable timeline. To communicate current activities and provide a forum for discussion and generation of new research and ideas leveraging social media and/or other communication platforms. To interact with the pharmaceutical sector and suggest evidence based solutions that can help prevent medication errors, especially in the case of look-alike and sound-alike medications. Evaluate and where appropriate recommend the need for meetings, education and/or affordable training, such as encouraging abstracts for the Annual Meeting and inputting into ISoP and chapter training meetings.

Primary care doctors traditionally provide a longitudinal and holistic view of their patients’ prescriptions, but there are barriers to general practitioners (GPs) carrying out effective reviews in complex patients with polypharmacy. These include unawareness of inappropriate prescribing; fear of the consequences of making changes to prescriptions; lack of self-efficacy (insufficient confidence to make changes); and lack of resources. GPs regularly carry out medication reviews for those taking multiple medicines, often with the support of pharmacists, but report a need for onward referral options to physicians specialising in multimorbidity and polypharmacy. In partnership with pharmacy colleagues, the authors of this study piloted an outpatient polypharmacy clinic, with the eventual hope of moving towards an integrated service. The pilot demonstrated the feasibility of establishing a specialist service in the secondary care or integrated care setting, dedicated to improving clinical outcomes for those experiencing problematic polypharmacy. This paper was published in Future Healthcare Journal.

Every registered medication has an information insert in its package. This patient leaflet provides information on the product, which includes clinical pharmacology, recommended dose, mode of administration, how supplied, and a large section contains warnings and contraindications, adverse reactions, and precautions. Most of the prescribers do not read the patient information leaflets and do not discuss it with the users, whereas some patients do read it thoroughly. This may create worries and uncertainties resulting in reduced compliance to treatment. With easy access of patients to information on drugs that they use, mainly through the electronic media, it is very important that the text and contents of these patient leaflets are simple to understand and readable. Although information from official health agencies is superior to net-based sources, the patient information leaflets should be improved and become more user-friendly and less frightening.

European drug regulations aim for a patient-centered approach, including involving patients in the pharmacovigilance (PV) systems. However many patient organisations have little experience on how they can participate in PV activities. The aim of this study published in Drug Safety, was to understand patient organisations’ perceptions of PV, the barriers they face when implementing PV activities, and their interaction with other stakeholders and suggest methods for the stimulation of patient organisations as promoters of PV. A sequential qualitative method study was conducted and integrated with the quantitative study performed by Matos, Weits, and van Hunsel to complete a mixed method study. The qualitative phase expands the understanding of the quantitative results from a previous study by broadening the knowledge on external barriers and internal barriers that patient organizations face when implementing PV activities. The strategies to stimulate patient-organisation participation are the creation of more awareness campaigns, more research that creates awareness, education for patient organisations, communication of real PV examples, creation of a targeted PV system, creation of a PV communication network that provides feedback to patients, improvement of understanding of all stakeholders, and a more proactive approach from national competent authorities. Both study phases show congruent results regarding patients’ involvement and the activities patient organisations perform to promote drug safety. Patient organisations progressively position themselves as stakeholders in PV, carrying out many activities that stimulate awareness and participation of their members in drug safety, but still face internal and external barriers that can hamper their involvement.

This Healthcare Safety Investigation Branch (HSIB) report sets out a case where a medication error with warfarin contributed to the death of a 79-year-old man. The patient had suffered a fall at home and had been admitted to hospital. An error on his chart whilst he was on the ward led to him receiving four or five doses of warfarin, which he did not normally take, before the error was spotted by a ward-based clinical pharmacist. The patient developed internal bleeding and deteriorated (due to several health reasons) and died 21 days after his first admission. Research published this year suggests that medication errors may directly cause around 712 deaths per year and indirectly contribute to 1,708. The report highlights the growing ageing population and that pharmaceutical care of older people can be complex. They are often taking multiple medications and are at the greatest risk of harm due to medicine-related errors. Recommendations As a result of the national investigation, HSIB has made three safety recommendations to facilitate better understanding of the role of the ward-based pharmacist, and to encourage best practice and resilience when identifying and developing models of pharmacy provision. It is recommended that NHS England and NHS Improvement carry out work to understand and further define the work of hospital clinical pharmacy teams, including the period between initial medicine reconciliation and discharge, in consultation with relevant stakeholders. It is recommended that the Royal Pharmaceutical Society, supported by NHS England and NHS Improvement, should provide guidance on models of hospital clinical pharmacy provision. The guidance should provide information on the models’ ability to enhance safety and healthcare resilience and include consideration of the appropriate skill mix and experience within the clinical pharmacy team. It is recommended that the NHS Specialist Pharmacy Service should update its resource on the prioritisation of hospital clinical pharmacy services to facilitate the dissemination of developments in good practice and policy with respect to pharmacy prioritisation and the issues highlighted in this report.

A review on the extent of medication errors and recommendations to reduce medication-related harm in England. The Short Life Working Group report makes recommendations for a programme of work to tackle medication error and improve medicine safety.

HSIB has identified a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge. A reference event was identified that resulted in a patient inadvertently receiving two anticoagulant medications at the same time, possibly causing an episode of gastrointestinal (digestive tract) bleeding. Increasingly, healthcare facilities in primary and secondary care are introducing digital solutions (electronic prescribing and medicines administration (ePMA) systems) to improve medicines safety. However, analysis of the reference event identified how ePMA systems can create their own risks, risks that will need to be addressed as these systems become more widespread. Other risk factors relating to prescribing and the discharge of the patient, including medicines reconciliation, availability of pharmacy services and weekend working, were identified during the investigation. Safety recommendations: It is recommended that NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System. It is recommended that NHSX supports the development of interoperability standards for medication messaging. It is recommended that NHSX continues its assessment of the ePRaSE pilot and considers making ePRaSE a mandatory annual reporting requirement for the assessment and assurance of electronic prescribing and medicines administration safety. It is recommended that the Department of Health and Social Care should consider how to prioritise the commissioning of research on human factors and clinical decision support systems; particularly in relation to the configuration of software system alerting and alert fatigue, to establish how best to maximise clinician response to high risk medication alerts. It is recommended that NHS England and NHS Improvement include in the Medication Safety Programme shared decision making and improved patient access to medication information across all sectors of care, to ensure a person-centred approach to safe and effective medicines use. It is recommended that NHSX produces guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process.

Examples and recommendations around how to implement some aspects from the Royal Pharmaceutical Society's report: Getting the medicines right.

Tackling antimicrobial resistance (AMR) and Healthcare Associated Infection (HAI) are currently a priority within healthcare and antimicrobial stewardship is an essential element of national and local programmes to address AMR. The aim of this webinar is to provide an overview of antimicrobial stewardship (AS), its importance in tackling Healthcare Associated Infection (HAI) and how pharmacists can contribute.

The Institute for Safe Medication Practices (ISMP) is the only nonprofit organisation in the US devoted entirely to preventing medication errors.  In this video, produced by ISMP in partnership with the Temple University School of Pharmacy, experts discuss medication safety concerns and offer practical error prevention recommendations.  This issue (episode 2) focuses on: the most common safety issues associated with measuring patient weight steps to eliminate drug concentration confusion understanding Patient Care Analgesia (PCA) by proxy.

This website allows patients and professionals to report suspected side effects to medicines or medical device and diagnostic adverse incidents used in coronavirus treatment to the Medicines and Healthcare products Regulatory Agency (MRHA) to ensure safe and effective use. When reporting patients and healthcare professionals are encouraged to provide as much information as possible.

The Specialist Pharmacy Service (SPS) is supporting healthcare professionals with the COVID-19 Vaccination Programme in England. Read about how they are helping and the resources available.

This guidance note is for general information purposes only. It is not exhaustive but does cover the essential elements needed for parties involved with pharmacy appeals.

Pharmacy teams may want to develop or implement new services in their organisations to realise quality, safety and operational benefits and financial efficiencies, or to improve the patient experience. The Pharmaceutical Journal highlights eight steps pharmacists should follow to ensure that a business case is as robust as possible. Top tips for preparing a business case: Write in the template and style your audience requires; Keep it clear and concise — use correct language that minimises jargon; Communicate all the facts clearly — this provides evidence you have done your homework; Ensure the reader clearly understands your vision and what you want to achieve; Make your writing interesting as stakeholders will need to read it; Ensure the ask to the organisation is clear and aligns with the strategic direction of the trust; Demonstrate any benefits clearly — financial, quality, safety or operational efficiencies; Demonstrate how any benefits will be realised within realistic timelines; Clearly highlight any risks and potential mitigations; Ensure financial costs/benefits have been validated by the finance team.