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Patient 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

Sara Riggare has had Parkinson's disease for nearly forty years. In this BMJ blog, she highlights the importance of trust and dialogue when making treatment decisions. Sara describes a recent interaction with a doctor to illustrate why listening to patients' concerns and answering their questions is vital to building mutual trust.

In this blog published by the Royal College of Nursing, Jean Almond, Programme Manager at Parkinson's UK, discusses improving the delivery of time critical Parkinson’s medication to care home residents.

Parkinson’s UK created the Tech Guide so that people with Parkinson’s, and their families, friends and carers, can make the right decisions for themselves about all the devices and apps that claim to be able to help improve their quality of life. To do this, they provide trusted reviews based on the lived experience of people with Parkinson’s, and maintain a catalogue of the various products that are on the market. This is backed up with information about Parkinson’s and evidence-based articles that will help you decide what’s right for you, in your unique circumstances.

This 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

In this blog, consultant geriatrician, Dr James Fisher, talks about a project at NHS Northumbria Healthcare to improve the experience of Parkinson’s patients by focusing on medication. Read other blogs and resources about Parkinson's shared on the hub in our Top picks: 11 resources about Parkinson’s

Parkinson'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.

South Tyneside and Sunderland NHS Foundation Trust is benchmarking against the Parkinson's UK10 recommendations for time critical medication to make sure that people with Parkinson’s get their medication on time, every time. Read on to find out how the team has listened to patients and focused their work.

This tool from the Parkinson's Association of Ireland allows people with Parkinson's to record their essential medical information in an easy to access format, should they need assistance or medical treatment. It includes: information about the physical symptoms of Parkinson's, including how it affects speech and movement. instructions on how to interact with the person if they are having difficulty communicating. personal details and emergency contacts details of medications and treatments the person is taking.

Falsified, fake or counterfeit medicines are medicines disguising themselves as authentic, and they can pose significant health risks. 96% of websites selling medicines operate illegally–but research suggests that over 50% of people are not aware of this. This blog highlights the issue of counterfeit Parkinson's medications being sold illegally online. Mike Isles, Executive Director of the Alliance for Safe Online Pharmacy in the EU describes their high prevalence and gives tips for people with Parkinson's on how to stay safe when buying medicines online.

Parkinson's UK have developed a number of training resources to help health and care staff provide safe care for patients with Parkinson's. Domiciliary care for someone with Parkinson's - 20 minute presentation for home care workers Introduction to Parkinson's for care staff course Omitted and delayed medicines on hospitals course Parkinson's awareness for ward staff - 15 minute presentation Parkinson's train the trainer course Parkinson's: Foundation modules for health and care staff

This guide, developed by Parkinson's UK, tells you how to manage someone with Parkinson's in an emergency situation. It will be particularly useful for professionals who don’t see people with Parkinson's day-to-day.