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News Article
Report finds ‘profound failings’ in Scottish NHS IT systems
Patient Safety Learning posted a news article in News
A Scottish Government committee has found that the “profound failings” of IT systems are the biggest problem facing a medicine-prescribing service that does not sufficiently focus on patients. A report from the members of Scottish Parliament on the Health and Sport Committee describes a medicines system “burdened by market forces, public sector administrative bureaucracy and under resourcing, inconsistent leadership and a lack of comprehensive, strategic thinking and imagination, allied to an almost complete absence of useable data”. The committee particularly criticised the failure of the NHS to introduce appropriate IT systems. “We are extremely disappointed that once again all roads lead to the dismal failure of the NHS in Scotland to implement comprehensive IT systems which maximise the use of patient data to provide a better service,” the report says. Committee members are calling for an overhaul of the system to allow for collection and analysis of data that would ensure the best possible outcomes for patients and cost savings for the NHS. MSPs found a “lack of care” to understand patients’ experience of taking medicines and a lack of follow up to ensure that medicines were effective or even being used. Prescribers were “instinctively reaching for the prescription pad” and not taking the time to discuss medicines with patients, nor were the principals of realistic medicine, in which patients and clinicians share decision making about their care, being followed. Read full story Source: Public Technology.net, 1 July 2020 -
Content ArticleThe Faculty of Pain Medicine of the Royal College of Anaesthetists is concerned with the professional standards of Pain Medicine specialists, so this document focuses on the Pain Medicine specialist’s contribution to Paediatric Pain Medicine (PPM). This document describes two levels of involvement in the practice of PPM: • The first level outlines the core knowledge, skills and attitudes for all anaesthetists specialising in Pain Medicine who may need to be involved with this area e.g. making timely and appropriate referrals for paediatric pain management and emergency management of a child with pain. Whilst it is recognised that not all Pain Medicine specialists will be directly involved in providing a paediatric pain service, all need to have an understanding of this area. • The second level outlines the advanced knowledge, skills and attitudes required of Pain Medicine specialists who work in teams providing a paediatric pain service. These competencies reflect those of the paediatric pain module which is an option at Advanced level of Pain Medicine training of the Royal College of Anaesthetists’ CCT in Anaesthetics curriculum, which sets out competencies for trainees who elect to take a deeper interest in this area of Pain Medicine practice
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Content ArticleThis resource, developed by UK healthcare professionals and policymakers, provides the information to support a safe and effective prescribing decision. Key Messages 1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain. 2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation). 3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit: tapering or stopping high dose opioids needs careful planning and collaboration. 4. If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available. 5. Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential.
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Content ArticleThis web page offers numerous resource pages which include: drug monitoring medicines management during this crisis summary of drugs for COVID-19.
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Content Article
MHRA guidance on Coronavirus (COVID-19)
PatientSafetyLearning Team posted an article in Guidance
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Content Article
Human medicines: highlights of 2019
Claire Cox posted an article in Medication including labelling
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Content ArticleThis study, published by Antimicrobial Resistance & Infection Control, shows that in hospital outpatient clinics, prophylaxis accounted for a quarter of the antimicrobial prescriptions and had in general a good guideline-adherence rate, with the exception of unnecessarily prescribed post-surgical/intervention prophylaxis, whereas a substantial part of the therapeutic prescriptions were inappropriate. Amoxicillin-clavulanic acid was the most inappropriately prescribed antimicrobial agent, regarding non-adherence to the guideline and also regarding the lack of considering renal function for dosage adjustment. Altogether, it is believed that antimicrobials prescribed at the hospital outpatient clinics warrant ASP attention. The variation of the guideline adherence rate between the investigated hospitals, as well as the differences with prior studies addressing antibiotic use in ambulatory settings in general, emphasise that (hospital) outpatient antimicrobial use should be audited locally.
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Content ArticleIssuing of controlled drugs within the operating department and key holding Ordering and transferring of drugs Unused controlled drugs Security requirements Disposal of controlled drugs.
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News ArticleThe toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, a new report warns today. The Healthcare and Safety Investigation Branch (HSIB) report focuses on propranolol, a cardiac drug that is now predominately used to treat migraine and anxiety symptoms. It is highly toxic when taken in large quantities and patients deteriorate quickly, making it difficult to treat. The investigation highlighted that these risks aren’t known widely enough by medical staff across the health service, whether issuing prescriptions to at risk patients, responding to overdose calls or carrying out emergency treatment. Dr Stephen Drage, ICU consultant and HSIB’s Director of Investigations, said: “Propranolol is a powerful and safe drug, benefitting patients across the country. However, what our investigation has highlighted is just how potent it can be in overdose. This safety risk spans every area of healthcare – from the GPs that initially prescribe the drug, to ambulance staff who respond to those urgent calls and the clinicians that administer emergency treatment." The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose. Read full story Source: HSIB, 6 February 2020
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Content ArticleSafety recommendations The safety recommendations are focused on: Updating clinical guidance (NICE) and the UK’s pharmaceutical reference source (the British National Formulary) on use of propranolol and highlighting the toxicity in overdose. National organisations supporting their staff membership to understand the risks when prescribing propranolol to certain patients. Improving the clinical oversight in ambulance control rooms and the treatment/transfer guidance for ambulance staff for propranolol/beta blocker overdose. As well as the safety recommendations, the report makes several safety observations and highlights some safety actions that have already been undertaken by NHS England and NHS Improvement, and the Medicines and Healthcare products Regulatory Agency. The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose.
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News ArticleLloydsPharmacy is piloting an innovative new service that offers extra help and support to mental health patients. Funded by The National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), which is a partnership between The University of Manchester and Salford Royal, the pilot is being carried out in ten community pharmacies in Greater Manchester. The new service, referred to as AMPLIPHY, enables pharmacists to provide personalised support to people who have been newly prescribed a medicine for depression or anxiety, or those who have experienced a recent change to their prescription. The pilot programme has been funded and designed by researchers at the NIHR GM PSTRC in collaboration with LloydsPharmacy. Central to the programme is the ability for patients to lead the direction of support they receive. They set their own goals and objectives and the pharmacist supports them in these. Professor Darren Ashcroft, Deputy Director of the NIHR Greater Manchester PSTRC, said: "The NIHR Greater Manchester PSTRC focuses on improving patient safety across four themes, which include Medication Safety and Mental Health. AMPLIPHY covers two of these areas and we believe it has the potential to make a difference to patients, by providing enhanced support for their care in the community." The pilot is set to run until April 2020 when its impact will be evaluated before a decision is made on the next steps. Read full story Source: News-Medical.net, 22 January 2020
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News Article
Ways to identify EHR usability issues and reduce patient harm
Patient Safety Learning posted a news article in News
An electronic health record (EHR) bug that transmits and medication order for 25 mg of a drug – not the prescribed 2.5 mg – could be the difference between life and death. And it’s that seemingly impossible reality that’s bringing more industry stakeholders to the table working to better understand EHR usability and its effects on patient safety. “Often times when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, Director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence. “In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured. All of those things shape usability.” EHR usability issues are an exceptionally common issue, Ratwani reported in a recent JAMA article. About 40% EHRs reported having an issue that can potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting. Direct safety challenges typically come from EHR products that are sub-optimally designed, developed, or implemented. Usability issues stem from a very cluttered interface or a complex medication list. Seeing a cluttered list can lead to a clinician selecting the wrong medication. A major usability issue also comes from data entry. EHR users want that process to be as clean as possible. Consistency in the way information is entered is also key, Ratwani explained. Ratwani also wants to ensure that certification testing is as realistic as possible. He compared it to when a vehicle is certified to meet certain safety standards each year. This type of mechanism does not exist when it comes to EHRs because right when the product is certified, it then gets implemented, and there is no further certification of safety done at all after the initial testing. “One way to do that, at least for hospitals, is to have that process be something that the Joint Commission looks to do as part of their accreditation standards,” Ratwani said. “They could introduce some very basic accreditation standards that promote hospitals to do some very basic safety testing.” Read full story Source: EHR Intelligence, 13 January 2020 -
Content ArticleThe study analysed whether the system generated clinically valid alerts and its estimated cost savings associated with potentially prevented adverse events. These alerts were compared to alerts in the CDS system, using a random sample of 300 alerts selected for medical record review. Findings showed a total of 10,668 alerts during the five-year period. Overall, 68.2% of the alerts would not have been generated by the existing CDS system. Ninety-two percent of a random sample of the chart-reviewed alerts were accurate based on structured data available in the record, and 80% were clinically valid. The estimated cost of adverse events potentially prevented in an outpatient setting was more than $60 per drug alert and $1.3 million when extrapolating the study’s findings to the full patient population.
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News ArticleTwo people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal. Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage. At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died. City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed. An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world." “As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.” Read full story Source: Chronicle Live, 22 December 2019
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Content ArticleSafety 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.
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Content ArticleThis document provides hospital and health system administrators and leaders with: specific improvement ideas for five system-level strategies that address the challenges of preventing, identifying and treating opioid use disorder brief case examples describing other hospitals’ approaches source literature and additional resources, including cost savings data, where applicable.
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News Article
Australia: ‘Medicine safety is a priority for us all.’
Patient Safety Learning posted a news article in News
Stakeholders from across various sectors in Australia attended a medicine safety forum convened in Canberra on Monday. Held by the Consumers Health Forum of Australia (CHF), Pharmaceutical Society of Australia (PSA), the Society of Hospital Pharmacists of Australia (SHPA), NPS MedicineWise and academic partners Monash University and University of Sydney, the forum challenged participants to ‘think differently’ on the safe use of medicines in Australia. This included brainstorming on what success in improving medicine safety would look like in 10 years. “Medicine safety is a priority for us all and we each have a role to play,” PSA National President Associate Professor Chris Freeman said. “It was inspiring to see the sector work together today to proactively identify those measures we can cooperatively pursue to make a real difference and protect patients.” Read full story Source: AJP.com.au -
Content ArticleThis webpage includes: an easy read leaflet about STOMP video challenging behaviour resources online medication pathway for family carers resources for healthcare professionals.
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News Article
Online prescribing 'must get safer'
Patient Safety Learning posted a news article in News
More deaths could occur unless action is taken to keep people safe when obtaining medications from online health providers, says a UK coroner. Nigel Parsley has written to Health Secretary Matt Hancock highlighting the case of a woman who died after obtaining opiate painkillers online. Debbie Headspeath, 41, got the medication, dispensed by UK pharmacies, after website consultations. Her own GP was unaware of what she had requested from doctors on the internet. The Suffolk coroner has now written to the Department of Health asking for urgent action to be taken. The General Pharmaceutical Council – the independent regulator for pharmacies – said it was responding to the coroner's report and would continue to take necessary action to make sure medicines are always supplied safely online. Read full story Source: BBC News, 9 December 2019 -
Content ArticleThis is an easy-read leaflet that you can download and print to give to your patients, service users, families and carers to inform them about STOMP.
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Content ArticleThis page is a catalogue of material to support CCGs, GP practices and others to undertake initiatives to support STOMP.
