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Content ArticleThis Healthcare and Safety Investigation Branch (HSIB) report explores the under recognised toxicity of propranolol in overdose. Propranolol is used to treat a number of medical conditions, including migraine, cardiovascular problems and the physical effects of anxiety. The case that prompted the investigation was Emma, a 24-year old woman, took an overdose of both propranolol and citalopram (an antidepressant). She called an ambulance, but her condition quickly worsened. Despite resuscitation efforts from both paramedics and medical staff in the hospital she was transferred to, Emma sadly died. There has been a steady rise in the number of propranolol prescriptions issued to NHS patients. Between 2012 and 2017 there was a 33% increase in the number of deaths reported as being linked to propranolol overdose, with 52 deaths recorded as having been linked to propranolol overdose in 2017.
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Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the prescribing of medicines for children based on their weight. This HSIB investigation reviewed the case of a four-year-old child who was diagnosed with a blood clot in her leg following a surgical procedure in hospital. She was prescribed an anticoagulant medicine using an electronic prescribing and medicines administration (ePMA) system. Errors in the prescription, dispensing and administration processes meant that the child received ten times the intended dose on five separate occasions over three days. A scan of the child’s brain showed evidence of a bleed and she was admitted to the paediatric intensive care unit. Following three months in hospital, the child was discharged home with an ongoing care plan.
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Content ArticleThe first meeting of the Independent Medicines and Medical Device Safety Review (IMMDS) Patient Reference Group took place on Thursday 25th February. The website contains summaries of all the meetings.
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Content ArticleWorld Patients Alliance is the umbrella organisation of patients and patients’ organisations around the globe. They seek to ensure that all patients have access to safe, high quality, and affordable healthcare everywhere in the world. These videos produced by World Patients Alliance provide information for patients on the following topics: How do you talk to your healthcare provider? An introduction to medication safety How many medications are too many?
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Content ArticleThis report by pharmaceutical company ViiV Healthcare focuses on results from wave two of their Positive Perspectives study. It investigates how people living with HIV (PLHIV) rate their own health and how living with HIV impacts their lives and affects their outlook for the future. It also examines their interactions and relationships with healthcare professionals and their experiences with antiretroviral treatment. The report highlights the importance of open and active dialogue and shared decision making between PLHIV and their healthcare professionals in improving outcomes.
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Content ArticleHappy Patient is a three-year project co-funded by the European Union, that seeks to reduce the impact of antimicrobial resistance (AMR) by decreasing the inappropriate use of antibiotics for the management of common community-acquired infection. Up to 25,000 people die every year in Europe as a direct consequence of the misuse of antibiotics, a figure that rises up to 30,000 in the United States (European Centre for Disease Prevention and Control). The Happy Patient Website offers a variety of communication tools for healthcare professionals and patients, including: Leaflet - Viruses or bacteria: What caused your infection? Urinary tract infections: A leaflet for older adults and their families Antibiotics prescription pad 5 myths about urinary tract infections (UTIs) in nursing home residents What you need to know if you have been prescribed an antibiotic
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Content ArticleOnline healthcare services and apps can help people take more control of their health, by getting access to care easily and when it suits them. This guidance for patients aims to help patients keep themselves safe when using online health services. Produced by a collaboration of UK health organisations, it includes six top tips for accessing healthcare online: Check if the online healthcare service and healthcare professionals working there are registered with UK regulators Ask questions about how the service works Answer questions honestly about your health and medical history Find out your options for treatment and how to take any medicines you’re prescribed Expect to be asked for consent for information to be shared with other healthcare professionals involved in your care Check what after-care you will receive
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World Health Organization: Patient engagement (December 2016)
Claire Cox posted an article in Patient engagement
This report is part of a technical series on safer primary care, published by the World Health Organization. The series explores the magnitude and nature of harm in the primary care setting from a number of different angles and provides some possible solutions and practical next steps for improving safety. The patient engagement report examines why it is important to involve people using services in improving safety and how this might best be done. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines. Some drugs, such as those used in anaesthesia and pain management, can cause patients to stop breathing. After administration, these drugs should be flushed through cannulae and extension lines to make sure no residual quantities of the drugs are left. Despite the issuing of multiple safety alerts over the past ten years, residual drugs in cannulae and extension line events continue to happen. When these events involve drugs that cause the patient to stop breathing, there is a risk of hypoxic brain injury (where the brain is damaged after a period where it does not get enough oxygen) or death. The investigation was launched after concerns were reported to HSIB by a consultant anaesthetist at a district general hospital where a patient had stopped breathing several hours after undergoing an anaesthetic. It’s thought that a quantity of the drug Suxamethonium - a muscle relaxant - was retained in their cannula after the procedure. The cannula containing the drug was flushed on the ward by a nurse preparing to administer intravenous paracetamol around three hours after the patient had returned from his procedure. The event was witnessed by a doctor who immediately started manual ventilation. The patient began to breathe spontaneously a few minutes later and suffered no physical harm. However, they have been left with a significant psychological impact following their experience of being awake but unable to move or breathe.
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Content Article"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
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Content ArticleSamantha Gould was 16 years old when she died by suicide due to an overdose of prescribed medication on 2 September 2018. She had borderline personality disorder that meant she was at risk of deliberate self-harm and suicide. In this report, the Coroner highlights concerns about a systemic weakness in the way in which Child and Adolescent Mental Health Services and primary care communicate with local pharmacies concerning 16-18 year old patients who are at risk of deliberate overdose. In spite of a safety plan agreed with Sam’s consultant psychiatrist whereby Sam’s parents would be responsible for her medication, Sam was able to pick up older prescriptions on 1 September 2018 without challenge, and it was those medications that were fatal in the combined amounts ingested by Sam.
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At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. To mark World Antimicrobial Awareness Week, which takes place every year in November, we’ve selected ten resources related to antimicrobial resistance. Shared with us by hub members and patient safety advocates, they provide valuable insights and practical guidance about AMR. -
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As clinicians, our primary objective is to provide the best possible care to our patients. In this pursuit, the administration of short-term intermittent IV antibiotics plays a crucial role in combating infections and saving lives; however, there is an under recognised issue, under delivery, that results in the misuse of antibiotics and could be exacerbating antimicrobial resistance. In this blog, Claire Davies, Clinical Therapy Manager at B. Braun Medical Ltd., explores the issue of under delivery and provides essential insights for clinicians to optimise their antibiotic therapy. -
Content ArticleChildren born to women who take valproate during pregnancy are at significant risk of birth defects and persistent developmental disorders. As such, it is vital that women and girls are dispensed valproate safely. The General Pharmaceutical Council is reminding all pharmacy professionals of what they must do to ensure women and girls receive the right information about valproate and the risk of birth defects. The update includes
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
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Content ArticleECRI’s Top 10 Patient Safety Concerns 2023 list identifies potential sources of danger for patients and staff. ECRI believe these risks require the greatest focus for the coming year and offer actionable recommendations for reducing these risks. ECRI conducts independent medical device evaluations, annually compiles scientific literature and patient safety events, concerns reported to or investigated by the organization, and other data sources to create its top 10 list.
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At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. Dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause. We have picked nine resources and reflections about keeping people with dementia safe in health and care settings, and when considering medication choices. -
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At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We’ve selected 14 useful resources about diabetes. Self-management is perhaps the most important aspect of treating diabetes effectively, so we've included some resources aimed at helping patients manage their diabetes too. Diabetes is a condition that causes the amount of glucose in a person's blood to be too high. When you have type 1 diabetes, your body can’t make any insulin at all, whereas with type 2, you either can’t make enough insulin, or it can’t work properly. There are also other types of diabetes including gestational diabetes, which some women develop during pregnancy, maturity onset diabetes of the young (MODY) and latent autoimmune diabetes in adults (LADA). It is important that people with diabetes are supported to maintain good blood glucose control through diet, insulin and other diabetes medications, to prevent both acute and long-term complications, -
Content ArticleThere are supply disruptions affecting various strengths of the following medications which are licensed for the treatment of attention deficit hyperactivity disorder (ADHD): methylphenidate (Equasym® XL) capsules, methylphenidate (Xaggitin XL® , Concerta XL® , Xenidate XL® ) prolonged-release tablets, lisdexamfetamine (Elvanse® ) capsules, and guanfacine (Intuniv® ) prolonged-release tablets. This is a safety critical and complex National Patient Safety Alert. Implementation should be co-ordinated by an executive lead (or equivalent role in organisations without executive boards) and supported by clinical leaders in pharmacy, community pharmacy, GP practices, mental health services and those working in the health and justice sector.
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Content ArticlePharmaswiss Česka republika s.r.o. and distributor Bausch & Lomb UK Limited is recalling all unexpired batches of Emerade 500 micrograms and Emerade 300 micrograms adrenaline auto-injectors (also referred to as pens) from patients. This is due to an issue identified during an ISO 11608 Design Assessment study where some auto-injectors failed to deliver the product or activated prematurely. Specifically, the 1-metre free-fall (vertical orientation) pre-conditioning resulted in damage to internal components of the auto-injector, leading either to failure to deliver the product or premature activation. This damage was not visibly apparent following the pre-conditioning but was evident only on subsequent functional testing. It is unclear what impact this has on auto-injectors in clinical use, however as a precautionary measure and owing to the inability to identify this issue before the auto-injectors are used, the auto-injectors are being recalled. Healthcare professionals should inform patients, or carers of patients, who carry Emerade 300 or 500 microgram auto-injector pens to obtain a prescription for and be supplied with an alternative brand. They should then be informed to return their Emerade 300 or 500 microgram pens to their local pharmacy.
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Content ArticleMacarthys Laboratories (trading as Martindale Pharma, an Ethypharm Group Company), has notified the MHRA that a limited number of Prenoxad kits (also called packs) in a batch marketed in France have missing needles. Naloxone is a drug that reverses the effects of an opioid overdose. If no needles are present in the kit, there is a risk that patients, members of the public and/or healthcare professionals may not be able to administer life-saving doses of naloxone from these kits in an emergency. This may impede the treatment for a patient with an opioid overdose, which may result in delay to intervention and possible death. Although no reports of UK marketed kits with missing needles have been received to date, the potential for kits to contain fewer than two needles in all distributed batches cannot be excluded based on the investigation by the company. However, due to the critical need for this product, the specified batches are not being recalled. This alert is for action by: primary and secondary care, specifically those involved in outreach services.
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Content ArticlePotassium permanganate is routinely used in the NHS as a dilute solution to treat weeping and blistering skin conditions, such as acute weeping/infected eczema and leg ulcers. It is not licensed as a medicine. Supplied in concentrated forms, either as a ‘tablet’ or a solution, it requires dilution before it is used as a soak or in the bath. These concentrated forms resemble an oral tablet or juice drink and if ingested are highly toxic; causing rapid swelling and bleeding of the lips and tongue, gross oropharyngeal oedema, local tissue necrosis, stridor, and gastrointestinal ulceration. Ingestion can be fatal due to gastrointestinal haemorrhage, acute respiratory distress syndrome and/or multiorgan failure. Even dilute solutions can be toxic if swallowed. A Patient Safety Alert issued in 20142 highlighted incidents where patients had inadvertently ingested the concentrated form, and the risks in relation to terminology and presenting tablets or solution in receptacles that imply they are for oral ingestion, such as plastic cups or jugs. A review of the National Reporting and Learning System over a two-year period identified that incidents of ingestion are still occurring. One report described an older patient dying from aspiration pneumonia and extensive laryngeal swelling after ingesting potassium permanganate tablets left by her bedside. Review of the other 34 incidents identified key themes: healthcare staff administering potassium permanganate orally patients taking potassium permanganate orally at home, or when left on a bedside locker potassium permanganate incorrectly prescribed as oral medication. The British Association of Dermatologists (BAD) ‘Recommendations to minimise risk of harm from potassium permanganate soaks’ includes advice on formulary management, prescribing, dispensing, storage, preparation and use, and waste.
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Content ArticlePatient safety alerts are issued to providers of NHS care to support them to take specific actions to keep patients safe. Although some content of past alerts is outdated, some of the actions from previously issued alerts continue to be relevant and remain valid beyond the timescales of the original alert. Over 140 alerts issued up to November 2019 (including ‘notices’ or ‘rapid response reports’) were recently clinically reviewed to identify which actions within those alerts remain valid and should be considered as ‘enduring standards’. The review covered alerts issued by the NHS England and NHS Improvement National Patient Safety Team and its predecessor organisation, the National Patient Safety Agency (NPSA). The review also summarised other content from the alerts identified as general principles that can be applied more widely to inform wider ongoing safety improvement. The key elements from the review are highlighted. The pages do not set out any new actions for organisations to implement, but act as an aid to support providers to confirm that ‘enduring standards’ from previously completed alerts have been embedded locally, and that the general principles are considered within ongoing patient safety improvement.
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Content ArticleIn this article, published by the Pharmaceutical Journal, Julia Robinson reviews the data and action taken so far to reduce avoidable harm caused by sodium valproate. Julia says that while there has been some progress in managing the risks of sodium valproate, babies are still being born after exposure to the drug, and safety concerns over antiepileptic use in men and women are multiplying.
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A bitter pill: Primodos (Sky News, 3 January 2023)
Patient-Safety-Learning posted an article in Medication
This Sky News investigation looks at one of the pharmaceutical industry's biggest scandals—the hormone pregnancy test Primodos which was prescribed to pregnant mothers in the UK between 1958 and 1978. Primodos was found to lead to birth defects, miscarriages and stillbirth, and regulatory failings led to avoidable harm to thousands of babies.
