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Content ArticlePharmacy teams should understand how to minimise the risk and likelihood of dispensing errors, including methods that can be used to evaluate existing processes, as well as how to deal with errors if they happen. This article from Phipps et al., in the Pharmaceutical Journal, builds upon the ideas proposed in ‘Understanding dispensing errors and risk’, and also proposes strategies and methods that should be considered for use in the pharmacy to manage the risk of dispensing errors.
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Content ArticleLaura Anne Jones MS (Member of the Senedd) tabled a formal written question concerning the implementation of the findings of the Cumberlege Review in Wales. This is the formal response from the Minister for Health and Social Services, Vaughan Gething MS.
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Content ArticleIn 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in their intensive care unit (ICU), Leslie et al. surveyed current practice in arterial line management and determined whether these recommendations had been adopted. They contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented – use of sodium chloride 0.9% as flush fluid, two‐person checking of fluids before use – and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two‐person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. This survey provides evidence of continuing risk to patients.
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Content ArticleSusan Warby, 57, was mistakenly given a glucose rather than a saline drip at West Suffolk Hospital after an operation for a perforated bowel in July 2018. Staff noticed a rise in blood sugar concentrations but gave her insulin to lower them rather than check the drip, which remained in place for 36 hours. In 2008 the National Patient Safety Agency made recommendations for safe arterial line management. In 2014 the Association of Anaesthetists published guidelines aimed specifically at preventing such events. Structured processes to prevent inadvertent use of a glucose-containing fluid to flush an arterial line and regular blood glucose sampling from a location other than the arterial line are only partial solutions. However, a survey of management of arterial lines undertaken in 2013 indicated that this was a common problem, that many of the NPSA recommendations were not widely implemented and that almost one third of respondents were aware of ‘wrong flush’ errors on their unit and a further third in other locations within their hospital. In this Rapid Response in the BMJ, Tim Cook says now is the time for patient representatives, clinicians, regulators and industry to work together to achieve widespread implementation of an engineered solution to prevent arterial line errors.
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Content ArticleIn 2008, the National Patient Safety Agency (NPSA) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose‐containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. Gupta and Cook report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. They report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. They discuss the nature of the errors that occurred and list the consequent changes in practice implemented in their unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.
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Content Article
Breastfeeding and medication
PatientSafetyLearning Team posted an article in Women's health
This website has been developed by Wendy Jones BSc, MSc, PhD, MRPharmS, a Community Pharmacist for over 40 years. This website is designed to provide information and support for mothers and healthcare professionals struggling to balance the benefits of breastfeeding with the perceived risk of exposing the baby to medication through his/her mother’s breastmilk.The information provided is based upon Wendy's many years experience gained as a pharmacist and from running the BfN national Drugs in Breastmilk Help-line. -
Content ArticleThis was a debate from the Scottish Parliament on the 8 September 2020 concerning the recommendations in the recently published First Do No Harm report by the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege (also known as the Cumberlege Review). The debate centred on a motion put forward by Jeane Freeman MSP, Cabinet Secretary for Health and Sport, which read as follows: That the Parliament welcomes the recommendations made by Baroness Cumberlege in her report on the independent medicines and medical devices safety review; acknowledges the Scottish Government's apology to women and families affected by Primodos, sodium valproate and transvaginal mesh; welcomes the Scottish Government’s commitment to establish a Patient Safety Commissioner, and notes the actions taken by the Scottish Government to offer improved services for women who have suffered complications as a result of transvaginal mesh.
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Content ArticleThis was a debate from the House of Lords on the 2 September 2020 on the second reading of the Medicines and Medical Devices Bill 2019-21. The intention of this bill is to confer power to amend or supplement the law relating to human medicines, veterinary medicines and medical devices; make provision about the enforcement of regulations, and the protection of health and safety, in relation to medical devices; and for connected purposes.
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Content ArticlePatients often carry medication lists to mitigate information loss across healthcare settings. The authors of this paper, published in BMJ Quality & Safety, aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use.
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Content ArticleThis document was drafted on the basis of the Transparency Committee opinion, French National Authority for Health, dated 27 February 2019. It found insufficient clinical benefit of ESMYA* for the treatment of uterine fibroids to justify reimbursement. They conclude: The actual clinical benefit of ESMYA is insufficient to justify its reimbursement by public funding in its two indications. Not approved for non-hospital pharmacy reimbursement or for hospital treatment. *ESMYA - (ulipristal acetate), progesterone receptor modulator.
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Content ArticleThis interview in the Journal of Quality and Patient Safety highlights the career and motivations of Dr. Gordon Schiff, a leader in patient safety whose has focused his efforts on improving medication safety, diagnostic safety and the role of information technology in enhancing care.
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Content ArticleHealthcare Quarterly is a Canadian publication and this issue, supported by the Canadian Patient Safety Institute (CPSI), focuses on patient safety.
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Content Article
Medication safety: "Know Check Ask"
Claire Cox posted an article in Resources for patients
Do you know your medicines? Do you keep a list? Can you describe and discuss your medicines with healthcare professionals and family when you want to? Keeping track of your medicines and communicating about them can be tricky as there can be so many details to remember. This is especially important if you have a healthcare appointment or are going to hospital. This "Know Check Ask" campaign website is here to help. Please click on the content below to learn more about taking medicines safely. -
Content Article
Medicines safety: NHS online learning index
Claire Cox posted an article in Medication including labelling
This alphabetical index helps NHS staff with an interest in the safe use of medicines to quickly find e-learning or videos that have already been produced by the NHS, government agencies, or professional bodies. -
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Antibiotic Resistance & Patient Safety Portal
Claire Cox posted an article in International patient safety
The Antibiotic Resistance & Patient Safety Portal (AR&PSP) is an interactive web-based application that was created to innovatively display data collected through CDC’s National Healthcare Safety Network (NHSN), the Antibiotic Resistance Laboratory Network (AR Lab Network), and other sources. It offers enhanced data visualizations on Antibiotic Resistance, Use, and Stewardship datasets as well as Healthcare-Associated Infection (HAI) data. -
Content ArticleThis YouTube video from nurse, Sophie Pig, aims to give you a better understanding of the 7 rights of medication administration. It is important to remember these 'rights' for every patient you encounter on a drug round.
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Content ArticleThe purpose of this study, published in the European Journal of Hospital Pharmacy, was to ascertain the views, beliefs and attitudes of hospital staff to incorrect penicillin allergy records in order to determine healthcare worker motivation for the implementation of a penicillin de-labelling antibiotic stewardship intervention at the study hospital. Findings showed that virtually all staff in this study, had encountered patients who believed themselves to be penicillin allergic, but felt the patient’s belief to be erroneous. Therefore, a penicillin allergy de-labelling intervention might be of benefit to ensure that patients who were not allergic were able to have the correct antibiotic.
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Content ArticleThe government-commissioned review, First Do No Harm, into why mesh implants and other treatments were allowed to harm hundreds of women said the failings were “caused and compounded by failings in the health system itself”. HSJ's Health Check podcast considers why it is being buried by government.
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Content ArticleOn Wednesday 8 July 2020 the Independent Medicines and Medical Devices Safety Review published its report First Do No Harm, examining how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. Chaired by Baroness Julia Cumberlege, the review focused on looking at what happened in relation to three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. In this blog Patient Safety Learning consider the reports findings in more detail, highlighting the key patient safety themes running through this, which are also found in many other patient safety scandals in the last twenty years. It also looks at what needs to change to prevent these issues recurring and asks whether NHS leaders stick with the current ways of working, make a few improvements, or take this opportunity for transformational change.
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Content ArticleUser-testing and subsequent modification of clinical guidelines increases health professionals’ information retrieval and comprehension, but no study has investigated whether this results in safer care. Jones et al. compared the frequency of medication errors when administering an intravenous medicine using the current National Health Service Injectable Medicines Guide (IMG) versus an IMG version revised with user-testing. Participants were on-duty nurses/midwives who regularly prepared intravenous medicines. Using a training manikin in their clinical area, participants administered a voriconazole infusion, a high-risk medicine requiring several steps to prepare. They were randomised to use current IMG guidelines or IMG guidelines revised with user-testing.
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Content ArticleThis Review was announced in the House of Commons on 21 February 2018 by Jeremy Hunt, the then Secretary of State for Health and Social Care. Its purpose is to examine how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices and to consider how to respond to them more quickly and effectively in the future. The Review was asked to investigate what had happened in respect of two medications and one medical device: hormone pregnancy tests (HPTs) – tests, such as Primodos, which were withdrawn from the market in the late 1970s and which are thought to be associated with birth defects and miscarriages; sodium valproate – an effective anti-epileptic drug which causes physical malformations, autism and developmental delay in many children when it is taken by their mothers during pregnancy; and pelvic mesh implants – used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. Its use has been linked to crippling, life- changing, complications; and to make recommendations for the future. The Review was prompted by patient-led campaigns that have run for years and, in the cases of valproate and Primodos over decades, drawing active support from their respective All-Party Parliamentary Groups and the media.
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Content Article
The Salford Medication Safety Dashboard (SMASH)
Claire Cox posted an article in Medication administration
The Salford Medication Safety Dashboard (SMASH) was successfully used in general practices with the help of on-site pharmacists. SMASH is a web application that flags up a list of patients who are potentially at risk from medicines they have been prescribed. -
Content ArticleDouble checking medication administration in hospitals is often standard practice, particularly for high-risk drugs, yet its effectiveness in reducing medication administration errors (MAEs) and improving patient outcomes remains unclear. This systematic review of studies, published in BMJ Quality & Safety, evaluates evidence of the effectiveness of double checking to reduce MAEs.
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Content ArticleThe aim of the Patient Safety and Access Initiative of India Foundation is to improve accessibility to safe and quality healthcare for all under Universal Health Coverage (UHC) and tackling the menace of spurious and not of standards medicines in the supply chain globally.
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Content ArticlePrimary care services provide an entry point into the health system which directly impact's people well-being and their use of other healthcare resources. Patient safety has been recognised as an issue of global importance for the past 10 years. Unsafe primary and ambulatory care results in greater morbidity, higher healthcare usage and economic costs. According to data from World Health Organization (WHO), the risk of a patient dying from preventable medical accident while receiving health care is 1 in 300, which is much higher than risk of dying while travelling in an airplane. Unsafe medication practices and inaccurate and delayed diagnosis are the most common causes of patient harm which affects millions of patients globally. However, the majority of the work has been focused on hospital care and there is very less understanding of what can be done to improve patient safety in primary care. Provision of safe primary care is priority as every day millions of people use primary care services across the world. The paper from Kuriakose et al., published in the Journal of Family Medicine and Primary Care, focuses on various aspects of patient safety, especially in the primary care settings and also provides some potential solutions in order to reduce patient harm as much as possible. Some important challenges regarding patient safety in India are also highlighted.
