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Content Article
As a patient receiving treatment for a bacterial infection through an IV administration set, commonly referred to as a drip, it’s essential to know that antibiotics play a crucial role in helping you get better. In this blog, Claire Davies, Clinical Therapy Manager at B. Braun Medical Ltd., explores an under-recognised issue that can affect your treatment, the unintentional under delivery of antibiotics via your drip. Claire explains why it’s important to ensure that all of your prescribed antibiotic dose is delivered via your drip and the measures being taken by healthcare providers to ensure that this happens. -
News Article
Private health firm Sciensus fails to fix defects that led to UK patient’s death
Patient Safety Learning posted a news article in News
A private health company paid millions by the NHS has failed to fix safety defects that led to the death of a cancer patient, the Guardian can reveal. Three patients were hospitalised and a fourth died when they were given the wrong doses of a powerful chemotherapy drug after a catastrophic IT failure at the medicine manufacturing unit of Sciensus in April this year. The incident, first revealed by the Guardian in July, prompted an investigation by the Medicines and Healthcare products Regulatory Agency (MHRA). Its inspectors found “significant deficiencies” at the Sciensus manufacturing facilities and ordered the partial suspension of its manufacturing licence. However, six months after the IT blunder, Sciensus has not fixed the problems identified by the regulator, according to people familiar with the matter. As a result, the suspension of its licence – originally due to be lifted last month – has been extended until July next year. Sciensus is the UK’s biggest provider of medicines services to NHS and private patients at home. It is contracted by the NHS and other organisations to deliver and administer medicines to more than 200,000 people with conditions such as heart disease, diabetes, dementia, HIV and cancer. Read full story Source: The Guardian, 5 November 2023 -
Content ArticleThe National Patient Safety Improvement Programmes (SIPs) collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system. SIPs aim to create continuous and sustainable improvement in settings such as maternity units, emergency departments, mental health trusts, GP practices and care homes. SIPs are delivered by local healthcare providers working directly with the National Patient Safety Improvement Programmes Team and through 15 regionally-based Patient Safety Collaboratives. The five National Patient Safety Improvement Programmes (NatPatSIP) are as follows: Managing Deterioration Safety Improvement Programme (ManDetSIP) Maternity and Neonatal Safety Improvement Programme (MatNeoSIP) Medicines Safety Improvement Programme (MedSIP) Adoption and Spread Safety Improvement Programme (A&S-SIP) Mental Health Safety Improvement Programme (MH-SIP) This report summarises the progress of the National Patient Safety Improvement Programmes.
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Content ArticleThe world is on the cusp of an ominous development: bacteria are building resistance to existing antibiotics faster than new antibiotics are entering the market. An ever-widening cavity is opening up. This 'antibiotic gap', as experts call this development, marks the beginning of a new era in medicine. For the first time in recent history, we have to come to terms with the fact that not all bacterial infections are treatable anymore - with implications for all areas of medicine, from surgery to oncology. The World Health Organization has been using the term "silent pandemic" since the fall of 2021 because, unlike Covid, antibiotic resistance is creeping into our society unnoticed - but it is shaking up our healthcare system just as overarchingly. Silent Pandemic shows how countries, scientists and private initiatives around the world are networking and forming alliances, and what strategies and measures they are using to counter the advance of antibiotic resistance.
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Content ArticleThe Extensive Care Service is part of the Fylde coast Vanguard and is designed for frail elderly patients with two or more long-term conditions who are at high-risk of an emergency admission. Working closely with patients, the service aims to assist them to improve their health and wellbeing; support them to manage their own conditions and provide effective interventions when needed in order to better manage exacerbations of their conditions. One of the key components of the care model is patient activation. The service teams’ understanding of an individual’s ability to contribute to the management of their own health and wellbeing is key to ensuring the success of this approach. The model is new, different and includes the development of a unique role - a ‘wellbeing support worker’. These individuals are a consistent feature in a model which enables a fuller understanding of a patient’s ‘activation’ ability so that engagement and support can be tailored appropriately.
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Content Article
Video: Living with schizophrenia (6 July 2023)
Patient-Safety-Learning posted an article in Mental health
In this video, Chris tells his story of how he dealt with a traumatic childhood and subsequent diagnosis of schizophrenia. He talks about the medication and therapy that have helped him. Warning: The film does contain references to distressing themes. -
Content Article
Top picks for Mental Health Day
Patient Safety Learning posted an article in Mental health
This year, WHO's World Mental Health Day on 10 October will focus on the theme 'Mental health is a universal human right'. To mark World Mental Health Day, we’ve pulled together 10 resources, blogs and reports from the hub that focus on improving patient safety across different aspects of mental health services. -
Content ArticleThis article in The Lancet aimed to review published work about the efficacy and safety of electroconvulsive therapy (ECT) with simulated ECT, ECT versus pharmacotherapy and different forms of ECT for patients with depressive illness. The authors designed a systematic overview and meta-analysis of randomised controlled trials and observational studies. They concluded that: ECT is an effective short-term treatment for depression, and is probably more effective than drug therapy. bilateral ECT is moderately more effective than unilateral ECT. high dose ECT is more effective than low dose.
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Content ArticlePublic and patient expectations of treatment influence health behaviours and decision-making. This study aimed to understand how the media has portrayed the therapeutic use of ketamine in psychiatry. It found that ketamine treatment was portrayed in an extremely positive light, with significant contributions of positive testimony from key opinion leaders (e.g. clinicians). Positive research results and ketamine's rapid antidepressant effec were frequently emphasised, with little reference to longer-term safety and efficacy. The study concluded that information pertinent to patient help-seeking and treatment expectations is being communicated through the media and supported by key opinion leaders, although some quotes go well beyond the evidence base. Clinicians should be aware of this and may need to address their patients’ beliefs directly.
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Content ArticlePeople with developmental disability have higher healthcare needs and lower life expectancy compared with the general population. Poor quality of care resulting from interpersonal and systemic discrimination may further entrench existing inequalities.
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Content ArticleThis report details the findings of a thematic review of Safe and wellbeing reviews (SWRs) between October 2021 and May 2022. SWRs are undertaken for children, young people and adults that are autistic and/or have a learning disability who are being cared for in a mental health inpatient setting. SWRs are part of the NHS response to the safeguarding adults review concerning the tragic deaths of Joanna, Jon, and Ben at Cawston Park Hospital, who were each detained for a long period of time and did not receive appropriate care.
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Content ArticleThe STOMP and STAMP programme of work is about making sure children and young people with a learning disability, autism or both are only prescribed the right medication, at the right time and for the right reason. This leaflet produced by Royal College of Paediatrics and Child Health and NHS England provides information to parents about psychotropic medicines.
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Content ArticleClinically focused presentation on Oliver's story from Steve Turner, given to the NICE Medicines & Prescribing Associates on 1 May 2019.
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Content ArticleHealth Education England and Skills for Care are working in partnership on the Oliver McGowan Mandatory Training trials in Learning Disability and Autism. This video tells Oliver’s Story and why the training is taking place.
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Content ArticleSTOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life. Psychotropic medicines affect how the brain works and include medicines for psychosis, depression, anxiety, sleep problems and epilepsy. Sometimes they are also given to people because their behaviour is seen as challenging. People with a learning disability, autism or both are more likely to be given these medicines than other people. These medicines are right for some people. They can help people stay safe and well. Sometimes there are other ways of helping people so they need less medicine or none at all.
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Content ArticlePublic Health England have estimated that on an average day in England, between 30,000 and 35,000 adults with a learning disability, autism or both are taking a prescribed antipsychotic, an antidepressant or both without appropriate clinical indications (psychosis or affective/anxiety disorder). A substantial proportion of people with a learning disability, autism or both who are prescribed psychotropic drugs for behavioural purposes can safely have their drugs reduced or withdrawn. This research showed that among adults known to their GP to have a learning disability, (excluding only those in hospital as inpatients) on any average day: 17.0% were taking prescribed antipsychotic drugs, 16.9% antidepressants, 7.1% drugs used in mania and hypomania, 4.2% anxiolytics and 2.7% hypnotics. STOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life.
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Content ArticleSTOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life.
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Content ArticleSTOMP stands for: stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life. Psychotropic medicines can cause problems if people take them for too long. Or take too high a dose. Or take them for the wrong reason. This can cause side effects like: putting on weight feeling tired or ‘drugged up’ serious problems with physical health.
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Content ArticleSteve Turner's blog discusses the use of psychotropic medicines for people with learning disabilities who show symptoms of distress. Steve offers a useful guide to help those prescribing these drugs consider all of the relevant factors so they can keep patients safe.
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Content ArticleThis video introduces England's 15 Patient Safety Collaboratives (hosted by Academic Health Science Networks) and how they support the NHS Patient Safety Strategy in areas such as COVID-19, managing deteriorating patients, maternal and neonatal safety, medicines safety, mental health and more. Download the slides here
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Content ArticleA rapid-learning report on the role of Patient Safety Collaboratives (PSCs) during the pandemic has been published by the AHSN Network. PSCs are just one part of the health and care system which responded quickly to the immediate crisis from COVID-19 in March. They reprioritised their day-to-day work and took on new programmes at speed, such as promoting safer tracheostomy care. The report has been published as part of the NHS Reset campaign and gives examples of how PSCs refocused their work ‘almost overnight’ to respond to the pandemic. It illustrates some of the creative ways AHSNs supported their local systems and how this experience will be built into future patient safety programmes.
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Content ArticleThis report from the AHSN Network shines light on ways we can do more to improve safety for residents of care homes. The publication showcases over 30 examples of projects delivered by England’s 15 Patient Safety Collaboratives (PSCs) and the Academic Health Science Networks (AHSNs) which host them. They include case studies in medicines safety, dementia, monitoring and screening, and workforce development.
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Content ArticlePrescribing errors in general practice are an expensive, preventable cause of safety incidents, illness, hospitalisations and even deaths. Serious errors affect one in 550 prescription items, while hazardous prescribing in general practice contributes to around 1 in 25 hospital admissions. Outcomes of a trial published in the Lancet showed a reduction in error rates of up to 50% following adoption of PINCER. PINCER is a methodology for reducing medication errors and, thereby, improving medication safety. Using clinical audit tools alongside quality improvement methodology to review groups of patients taking high risk medicines/combinations of medicines, PINCER ensures that any risks are mitigated.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) investigated the case study of Martin, a 43-year old inmate, who suffered multiple seizures after his epilepsy medication wasn’t transferred with him to a new prison. Each day around 120 prisoners with ongoing medication needs are moved between jails. Martin’s case is just one example of a serious outcome when medication was missed. Prisoners may also need to be treated in the community at local hospitals, with prison security staff being taken away from planned duties to accompany them.
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Content Article
The Oslo Medicines Initiative
Sam posted an article in Other countries and national agencies
The Oslo Medicines Initiative: “better access to effective, novel, high-priced medicines – a new vision for collaboration between the public and private sectors” is a new initiative of WHO/Europe, developed together with the Norwegian Ministry of Health and Care Services and the Norwegian Medicines Agency. The Initiative will provide a neutral platform for the public and private sectors to jointly outline a vision for equitable and sustainable access to effective, innovative and affordable medicines.
