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Found 59 results
  1. News Article
    The 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
  2. Content Article
    Safety 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.
  3. News Article
    LloydsPharmacy 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
  4. News Article
    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
  5. Content Article
    The 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.
  6. News Article
    Two 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
  7. Content Article
    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.
  8. Content Article
    This 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.
  9. News Article
    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
  10. Content Article
    This webpage includes: an easy read leaflet about STOMP video challenging behaviour resources online medication pathway for family carers resources for healthcare professionals.
  11. News Article
    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
  12. Content Article
    This 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.
  13. Content Article
    This page is a catalogue of material to support CCGs, GP practices and others to undertake initiatives to support STOMP.
  14. Content Article
    This video by the NHS England STOMP team and service users, explains what STOMP is and what frontline staff need to know.
  15. News Article
    Greater Manchester community pharmacies have signed up to a new national scheme, which will see patient consultations booked via NHS 111 for the very first time. The scheme launched on the 29 October is part of major plans to boost the role of pharmacists in patient care, outlined in the national NHS Long Term Plan. People who call the free NHS 111 phone service can now be offered same day consultation with their local community pharmacist, if they need an urgent supply of a prescription medicine or advice on minor illnesses. The aim of the scheme is to leverage pressure on GP practices and A&E departments, which come under increasing strain when the winter hits. Early stages of the initiative in other parts of the country found that an estimated 6% of all GP consultations could be handled by a community pharmacist, freeing up around 20 million GP appointments each year nationally. Sarah Price, Executive Lead for Population Health and Commissioning at Greater Manchester Health and Social Care Partnership said: “Our health services are facing unprecedented challenges and that means finding new ways to deliver the standard of care that patients expect, whilst ensuring that services are sustainable and fit for the future. Doing things the way we’ve always done, is no longer an option. Greater Manchester pharmacists are rising to the challenge and becoming more closely involved in patient care, often in close partnership with other health and care professionals." Read full story Source: National Health Executive, 4 December 2019
  16. Content Article
    This study from Schultz et al., published in the The Canadian Journal of Hospital Pharmacy, clearly shows hat abbreviations currently used by manufacturers to differentiate short- and long-acting medications are problematic. Furthermore, it has highlighted the potential consequences of using non-intuitive abbreviations to differentiate medications with different release rates. The study demonstrates how evidence-based research at the local level, along with feedback and input from front-line staff, can be used to address longstanding problems. Although no strategy can eliminate all errors involving medications with different release rates, this study generated evidence-based solutions that were subsequently implemented to minimise potential errors through more intuitive labelling of medications. The findings from this evaluation are applicable to other organisations seeking to reduce the risk of errors related to medication abbreviations and should also be considered by pharmaceutical companies.
  17. News Article
    More than 2.8 million antibiotic-resistant infections occur in the U.S. every year, and more than 35,000 people die as a result of those infections, according to a newly released Centers for Disease Control and Prevention (CDC) report. The updated Antibiotic Resistance Threats in the United States (AR Threats Report) also estimates when antibiotic-resistant bacterium Clostridium difficile (or C. diff) is included, that number exceeds 3 million infections and 48,000 deaths. The report, which used data sources such as electronic health records not previously available, shows that there were nearly twice as many annual deaths from antibiotic-resistant infections as the CDC originally reported in 2013. CDC officials called the numbers in this report "more precise, though still conservative, estimates of the human costs of antibiotic resistance. Read full story Source: FierceHealthcare, 13 November 2019
  18. Community Post
    Hi everybody This is Jaione from Spain (we are in the North, Basque Region) and i am a nurse working in collaboration with the Patient Safety Team in our local NHS (Basque Health Service). First of all, I would like to congratulate the team for this hub which i think is a wonderful idea. Secondly, i would like to apologize for the language, since, although i lived in England many years ago, that is not the case anymore and I'm afraid i don't speak as well as I used to. I would like to comment a problem that we encounter very often in our organization which is related to patient's regular medications when they are admitted to hospital. We do have online prescriptions for both acute and community settings but the programs don't really speak to each other so, for example, if I take a blood pressure pill everyday and i get admitted into hospital, chances are that my blood pressure tablet won't get prescribed during my in-hospital stay. The logical thing to do would be to change both online systems so they communicate to each other, but that's not possible at the moment. I wanted to ask whether other systems have the same problem and, if so, if there is any strategy implemented to alleviate this issue. I hope i have expressed myself as clearly as possible. Thanks very much once more for this hub! Kind regards Jaione
  19. Content Article
    The toolkit includes presentations and tools to support implementation of the Four Moments and improve antibiotic prescribing, encompassing three critical areas: Developing and improving your antibiotic stewardship programme, Creating a culture of safety around antibiotic prescribing in your hospital, and Learning and disseminating best practices for the diagnosis and treatment of common infectious disease syndromes.
  20. Content Article
    The focus of this CwPAMS project is antimicrobial stewardship, which aims to improve the use of antimicrobials using the expertise of pharmacists and so tackling antimicrobial resistance (AMR); a threat that the World Health Organization (WHO) states currently causes 700,000 deaths per year, which will increase to 10 million worldwide by 2050,[1] and could disrupt the cornerstones of current medicines, such as cancer management and joint replacements.[2] Zambia is lower-middle income country but has a very high burden of infectious diseases, including high morbidity and mortality rates from HIV, lower respiratory tract infections, malaria, diarrhoeal diseases and tuberculosis.[3],[4]University Teaching Hospital (UTH) has reported very high AMR rates to a variety of key antimicrobials and while they were aware of antimicrobial stewardship they didn’t proactively engage with it. WHO has developed an AMS framework with four key components: AMR awareness, appropriate use of antimicrobials, infection prevention and control, and surveillance. Using this framework, our small team from Brighton & Sussex University Trust, UTH and UNZA organised a stakeholders meeting and ‘train the trainers’ event to develop key interventions to improve antimicrobial stewardship at UTH. The three-day event was held in June 2019 in Lusaka and had excellent engagement from doctors, pharmacists and environmental health professionals from UTH plus representatives from Zambian Ministry of Health, THET, Hospital Pharmacist Association of Zambia, University of Zambia and Zambian Medicines Regulatory Authority. The three-day event was a hive of energy, highlighting the Zambian interest and commitment to AMS and improving outcomes for their people, from grass roots to ministerial level. The main outcomes from the event were: To conduct global point prevalence survey (GPPS) for antimicrobial surveillance. To develop and implement an antimicrobial specific drug chart which can improve prescribing practices. To implement a bare below the elbows (BBE) dress code change to improve infection prevention and control. To implement an infection prevention and control and antimicrobial stewardship training programme. To employ an antimicrobial specialist pharmacist to be the guardian of above outcomes. Data collection was a daunting task for our UTH colleagues, so while in Zambia we volunteered to help with data collection for the GPPS pilot. This was a huge success, highlighting how quick and simple the process could be plus the useful data outputs it enabled. From this, we were able to get first-hand experience in UTH, which was invaluable for future programme development; the hospital is huge and sprawling, with little or no access to computers. Six-bedded bays held 11-beds and outpatient pharmacy requests were often above 700 per day. BBE and infection prevention and control were not present, with staff having to wear long-sleeved white lab coats and hand sanitising stations being woefully lacking. Despite these conditions all staff were committed to patient care and safety, and their enthusiasm for improvement has led to speedy employment of an antimicrobial pharmacist at UTH plus development of UTH antimicrobial guidelines, both of which will improve antimicrobial usage. One of our first priorities has been infection prevention and control implementation by utilising neighbouring Ndola Teaching Hospital's experience to conduct more ‘train the trainers’ sessions on handwashing technique, alcohol gel production and use, and BBE requirements. Uniquely we have organised this at hospital level (rather than external workshops) as we have found a larger and more diverse cadre of hospital staff are then able to attend (including nurses, porters and cleaning staff) and minimises patient care disruption and enables a whole hospital approach plus doesn’t require unobtainable technology. These trainers will now disseminate this information among their colleagues and an audit of implementation and practice is planned. Our second drive is implementation of the antimicrobial drug chart with GPPS to determine if the additional chart is effective in improving antimicrobial use. All these initiatives require training to ensure staff are aware of the importance of the initiative and its intended outcomes. We are also now exploring ways to make antimicrobial stewardship training mandated during staff induction. Once this baseline knowledge is established, we can continue to develop more complex training to develop skills and knowledge further and support clinical excellence. We have overcome many challenges to produce these outputs. The distance, lack of conference calling ability and rolling electricity shortages could make communication difficult, but we have employed weekly Zoom calls plus Trello online storage, which require smartphones only, to overcome these issues and this has been very successful and kept us to deadlines. Additionally, we have aimed for the Brighton & Sussex University Trust role to be supportive rather than directive to ensure that projects are owned and used by UTH colleagues and so more sustainable. We have tried to ensure that all tools are culturally appropriate and so more likely to be engaged with, such as newly developed infection prevention and control posters that have UTH staff promoting the initiative. During the workshop we noted Zambian staff enjoyed learning through games and case studies and so (in collaboration with Focus games) we have developed a Sepsis; Zambia board game and are now developing case studies using the new UTH antimicrobial guidelines. A reciprocal visit for UTH staff to experience life in the NHS was also arranged; this has included attendance on ward rounds, shadowing of staff, education observations (in Trust and at local university) and the UKCPA conference. Our feedback sessions have highlighted that there are more commonalities between our hospitals than differences; while the diseases and drugs may be different we are all working in resource tight settings trying to do the best for our patients. A repeating feedback theme though was that there was a more cohesive multi-disciplinary approach to antimicrobial stewardship at Brighton & Sussex University Trust and UTH would like to emulate this; we hope this has been started by involving doctors in the visit, mentoring of antimicrobial stewardship pharmacist and inclusive antimicrobial stewardship / infection prevention and control training and chart development. Future suggestions included undergraduate MDT training and pharmacy induction for medics. As expected, this project has allowed me to fulfil humanitarian aspects that I wanted to achieve. Unexpectedly, I have also seen a development in my problem-solving skills, teaching methods (especially when there is scant technology available), negotiation and leadership skills, which I can then apply to my daily job back in the NHS. Importantly this opportunity has enabled me to really feel like I am given back to the (global) community and provide immense job satisfaction in an area of important global challenge; I encourage anyone with an interest to become involved. References: World Health Organisation. 2016. https://www.who.int/bulletin/volumes/94/9/16-020916/en/ [Accessed 10/11/19]. World Health Organisation. Antimicrobial Resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance [Accessed 10/11/19]. Institute for Health Metrics and Evaluation. GBD Compare. Zambia. https://vizhub.healthdata.org/gbd-compare/ [Accessed 10/11/19]. World Health Organisation. Zambia: WHO Statistical Profile. https://www.who.int/gho/countries/zmb.pdf [Accessed 10/11/19].