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Content ArticleThe National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is an independent body composed of 27 national organisations. In 1995, the United States Pharmacopeial Convention (USP) spearheaded the formation of the National Coordinating Council for Medication Error Reporting and Prevention: Leading national health care organizations are meeting, collaborating, and cooperating to address the interdisciplinary causes of errors and to promote the safe use of medications.
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This year's World Patient Safety Day, due to take place on Saturday 17 September 2022, will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. In this blog for the hub, Laurence Goldberg, an independent pharmaceutical consultant, looks at how we can reduce drug administration errors by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient. -
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This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list six helpful reads related to medication safety in hospital settings. -
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Angela talks to us about how her role enables her to promote collaboration for patient safety between different layers of the healthcare system. She also tells us about how Northern Ireland is using World Patient Safety Day 2022 to help the public and healthcare staff understand how they can contribute to medication safety. -
Content ArticleThis article and video tell the story of Rihan Neupane, a baby born prematurely in Dhapasi, Nepal, who was left in a vegetative state following a series of medical errors including a missed diagnosis of meningitis. His parents had chosen a private international hospital for their maternity care, but were let down by a series of medical errors including Rihan being mistakenly given a massive paracetamol overdose. Although external hospital safety inspectors found the hospital negligent on many counts, the hospital continued to deny any wrongdoing or responsibility for Rihan's condition. Rihan's father Sanjeev Neupane talks about his family's experience in the embedded video.
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This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here -
Content ArticleIn this article, Maryanne Demasi looks at the continued prescription of Makena, an injectable synthetic hormone approved by the US Food and Drug Administration (FDA) to women who are at high-risk of premature delivery. Makena claims to reduce the risk of pre-term birth and was approved in 2011 on an accelerated pathway by the FDA following an initial trial that showed positive outcomes. However, Demasi explains, the study has been discredited as flawed in its methods and findings, and a confirmatory trial conducted by the manufacturer showed that Makena does not actually prevent preterm birth. In spite of this, and in the face of known risks, Makena is still being prescribed to pregnant women as the manufacturer has refused to withdraw it from the market. She highlights the dangers of the FDA not taking stronger action against the manufacturer of Makena, by looking at the example of Diethylstilbestrol (DES), a synthetic hormone use by women from the 1930's to the 1970s to prevent miscarriages and premature births. DES was later found to cause cancers, immune and cardiovascular disorders and other abnormalities in pregnant women, their children and their grandchildren.
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Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. In recognition of this, in 2017 the World Health Organization (WHO) launched the Third WHO Global Patient Safety Challenge: Medication Without Harm, aimed at improving medication safety. This article provides information and resources related to the Challenge. -
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Soojin talks to us about how her personal experience of harm motivated her to work in healthcare and campaign for patient safety, the power of collaboration in improving healthcare safety and how healthcare workers can take steps to improve their own patient interactions. -
Content ArticleAlcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioural health condition. The aims of this paper from Zipperer et al. are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population.
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Laurence Goldberg, an independent pharmaceutical consultant, discusses the effectiveness and also the potential for harm of unit-dose medicines distribution. -
Content ArticleThis is the first in a new series of ‘In Conversation with’ podcasts from the All Party Parliamentary Group (APPG) on First Do No Harm. In this episode Lord Philip Hunt discusses the key achievements of the Health and Care Act 2022 of relevance to the APPG’s work, and the areas still left to address. The APPG on First Do No Harm is a group of parliamentarians who are committed to raising awareness of and building support for the recommendations in First Do No Harm, the report of the Independent Medicines and Medical Devices Safety Review, and to ensure the implementation of the recommendations by the UK Government and others.
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WHO: World Patient Safety Day 2022
Patient Safety Learning posted an article in WHO
This year World Patient Safety Day, due to take place on Saturday 17 September 2022, will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. This page links to resources to mark World Patient Safety Day from the official World Health Organization (WHO) website.- Posted
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Content ArticleThis report by the consultancy firm Deloitte looks at patient safety across biopharmaceutical (biopharma) value chains, arguing that change is needed to make medications safer for patients and add value to pharmaceutical products. The authors highlight that there is currently great potential for strategies to increase safety, improve equity and enhance patient engagement and experience. Advances in artificial intelligence (AI) technologies and data analytics, combined with increased incidence of adverse event reports (AERs) and increasing expectation of more personalised, preventative, predictive and participatory (4P) medicine, present an opportunity to improve pharmacovigilance.
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Content ArticleThis blog on the NHS England website looks at how Written Medicine, a service that provides bilingual medication information, is helping to reduce healthcare inequalities and medical errors in London. Written Medicine’s software allows pharmacies and hospitals to translate and print medication information, instructions and warnings. Drawn from a dataset of 3,500 phrases, printed labels are available in fifteen different languages. The bilingual labels help patients take ownership of their treatment, giving them a better understanding of how to take their prescribed medication. The solution is helping to reduce errors, improve medication adherence and enhance patient safety and experience. The blog also looks at the experience of London North West University Healthcare NHS Trust (LNWH) using Written Medicine. A 2019 audit showed that the service was valued by patients and highly successful in increasing medication adherence through empowering patients.
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Content ArticleIn the 2017 Health Survey for England, 34% of adults reported experiencing chronic pain. The survey found that 5.5 million people (12%) are affected by high-impact pain that prevents them from enjoying social, family and recreational activities, and from working, including carrying out household tasks. This document sets out what the Arthritis and Musculoskeletal Alliance (ARMA) believes should be available in every area for people living with long term pain. It covers four areas: Underpinning framework Treatment for underlying conditions Services for people living with chronic pain Prevention and inequalities
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Content ArticleEach year, 7,000 to 9,000 people die as a result of a medication errors in the US, and the total cost of looking after patients with medication-associated errors exceeds $40 billion. Alongside this financial cost, adverse events caused by medication errors also cause patients significant psychological and physical pain and suffering. The article aims to: identify the most common medication errors. review some of the critical points at which medication errors are most likely to occur. outline strategies to prevent medication errors occurring. summarise multidisciplinary team strategies for decreasing medication errors.
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Content ArticleThis article in DIA Global Forum examines a new collaboration between the European Commission, the European Medicines Agency (EMA) EU Member States Belgium, France, and Germany, the Bill & Melinda Gates Foundation and the recently established African Medicines Agency (AMA). The group will mobilise more than €100 million over the next five years to support the AMA and other African medicines regulatory initiatives at regional and national levels. The initiative will foster collaboration and sharing of technical expertise by European regulators with AMA. It also aims to assist African national regulatory authorities (NRAs) in achieving the minimum World Health Organization (WHO) requirements for effective regulatory oversight of quality-assured, safe, local production of medicines and vaccines.
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In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the safety issues faced by people with diabetes in hospital settings. Reflecting on feedback from Twitter users with diabetes, she looks at why so many people with diabetes fear having to stay in hospital, and asks what the NHS and its staff can do to make it a safer, less stressful environment. -
Content ArticleFracture liaison services (FLSs) check if people who have recently broken a bone after falling from a standing height or less (a fragility fracture) might also have osteoporosis – a disease that weakens bones. They then advise on treatments to reduce the risk of another fracture, helping to improve patient outcomes. The Royal College of Physicians (RCP) estimates that at least 90,000 patients in England and Wales who should have anti-osteoporosis therapy are not receiving it. This guide by the RCP's Fracture Liaison Service Database (FLS-DB) aims to help patients and their families and carers understand what to expect following a fragility fracture. It outlines three key findings and the actions that individuals can take to ensure they receive the care and treatment they need from health services.
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Content ArticleThe Medicines and Healthcare product Regulatory Agency’s (MHRA) Annual Report and Accounts for 2021/22 has now been published. It provides an overview of MHRA's performance and the events that have had most impact on the Agency during the past year.
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Content ArticleDrugwatch is a US consumer advocacy organisation that works with certified medical and legal experts to educate the public on dangerous drugs and medical devices and to empower consumers to assert their legal rights. In this article, Terry Turner, writer for Drugwatch, examines the history of the medical tech company C.R. Bard, which specialises in vascular, urology, surgery and oncology devices. Bard manufactures thousands of medical devices and sells them worldwide. The article looks at how the company was established and then examines several legal issues Bard has faced, including criminal charges stemming from medical fraud and accusations of selling defective devices that have killed patients or caused serious complications. The author looks at criminal charges concerning heart catheters to which Bard pleaded guilty. They also highlight problems with Bard's transvaginal and hernia mesh products and inferior vena cava (IVC) filters—devices designed to catch blood clots before they reach the lungs or the heart.
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Content ArticleWorld Pharmacist Day is an initiative by the International Pharmaceutical Federation (FIP) to promote the role that pharmacists play in improving patient safety. In this blog, Roohil Yusuf, Global Pharmacy Advisor at Save the Children, looks at the work of different partners in delivering safe pharmacy services in Afghanistan, Yemen and Sudan.
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Content ArticleThe APPG held their annual general meeting in Parliament. Baroness Cumberlege was re-elected as Co-Chair of the group and in light of Jeremy Hunt’s recent appointment as Chancellor of the Exchequer, Sharon Hodgson MP was elected as Co-Chair, having previously supported the Group as Vice-Chair over the last calendar year. Sharon is is an Officer of the APPG for Valproate and other Anti-Epileptic Drugs in Pregnancy and Vice-Chair of the All-Party Parliamentary Group on Surgical Mesh. The current serving Vice-Chairs were re-elected, with the addition of Baroness Ritchie also joining as Vice-Chair. The Group looked back on a year of significant activity and progress, including the appointment of Dr Henrietta Hughes as the first Patient Safety Commissioner in England, and agreed that a renewed focus on seeking the implementation of redress schemes should be a priority for the Group over the next year.
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Content ArticleThis survey by In-FACT (Independent Fetal Anti Convulsant Trust) is intended to provide patients, no matter what anti-epileptic drug (AED) they are prescribed or what condition the AED is prescribed for, the opportunity to report problems and worries about taking their medication during pregnancy. The results will be used to inform In-FACT's ongoing work to improve medication safety and their engagement with the Medicines and Healthcare products Regulatory Agency (MHRA).
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