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Content ArticleThis document sets out the Northern Ireland Department of Health's ambitions to improve medication safety in Northern Ireland, in line with the World Health Organization's Third Global Patient Safety Challenge 'Medication without Harm'. It outlines the need for safer use of medicines in Northern Ireland and highlights four ways in which the Department for Health will address these challenges: Engagement with patients and the public Introducing new systems and practice Engagement and training of health and social care staff Reducing the burden of avoidable harm from high-risk medicines by building good practice in to the supply of all medications
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Content ArticleThis article in the British Journal of Clinical Pharmacology aimed to calculate the medication costs of potentially inappropriate prescribing for middle-aged adults compare with the cost of consensus-validated, evidence-based, ‘adequate’ alternative prescribing scenarios. It used a Delphi consensus panel and cross-sectional study to examine primary care data of 55,880 patients aged 45-64 years old in South London. The study found that duplicate drug classes was the most costly criterion for both PIP and alternative prescribing. It identified no substantial cost difference between adequate prescribing versus PIP and the authors recommend that future studies investigate the wider health economic costs of alternative prescribing, such as reducing hospital admissions.
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Content ArticleThis article in the journal JAMA Network Open aimed to determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish antibiotic stewardship programs focusing on patient safety, is associated with reductions in antibiotic use in long term care settings. The authors looked at 439 long term care settings and found that participation in training on antibiotic stewardship from AHRQ was associated with a reduction in antibiotic use and urine culture collection. Fluoroquinolones, an antibiotic class targeted by the AHRQ safety program, had the greatest decrease.
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Content ArticleUnsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. The World Health Organization (WHO) has launched the Third WHO Global Patient Safety Challenge: Medication Without Harm to improve medication safety. Considering the huge burden of medication-related harm, Medication Safety has also been selected as theme for World Patient Safety Day 2022. WHO has launched a series of webinars to introduce the strategic framework for implementation of the Challenge, technical strategies, tools and provide technical support to countries for reducing medication-related harm. The webinars share country and patient experiences in implementing the Challenge. This webinar focuses on the role of patients and their families in improving medication safety, recognising that they are the only constants in increasingly complex healthcare systems, and that they can provide essential information and feedback.
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Content ArticleMedication errors can occur at any point in the system for prescribing, dispensing and administering drugs in the NHS – and can often be the result of human errors creeping in as burned out staff misread or miscalculate the amount needed. This article in the Health Services Journal examines how closed loop medication management systems can improve patient safety by ensuring patients are prescribed the right dosage of the right medications. The author speaks to Islam Elkonaissi, former lead pharmacist for cancer services in Cambridge, about the importance of well-planned implementation and bridging the gap between IT specialists and healthcare workers to make sure that potential for communication errors is minimised. They also discuss the value of the huge amounts of data AI systems can collect, which in turn make the systems more precise and accurate.
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Content ArticleAntibiotic resistance is a growing issue for medicine globally, so finding alternative medications is a priority for medical research. This study in The BMJ aimed to test and compare the efficacy of methenamine hippurate with the current standard use of daily low dose antibiotics to prevent recurrent urinary tract infections in women. The authors of the study concluded that non-antibiotic prophylactic treatment with methenamine hippurate might be appropriate for women with a history of recurrent episodes of urinary tract infections. The study demonstrated that the treatment had a similar success rate as daily antibiotic prophylaxis.
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Content ArticleUnsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. The World Health Organization (WHO) has launched the Third WHO Global Patient Safety Challenge: Medication Without Harm to improve medication safety. Considering the huge burden of medication-related harm, Medication Safety has also been selected as theme for World Patient Safety Day 2022. WHO is launching a series of webinars to introduce the strategic framework for implementation of the Challenge, technical strategies, tools and provide technical support to countries for reducing medication-related harm. The webinars will share country and patient experiences in implementing the Challenge. These presentations from the opening webinar sets out the urgency to address the challenge, the strategic framework and progress to date.
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Content Article
WHO: World Antimicrobial Awareness Week 2021
Patient-Safety-Learning posted an article in Medication
World Antimicrobial Awareness Week takes place from the 18-24 November every year. On this page the WHO explains what antimicrobial resistance is and provides several short explanatory videos about how this can be prevented. -
Content ArticleThis study, published in JAMA Network Open, looks at whether publicly reported feedback was associated with hospital improvement in an evaluation of medication-related safety performance. The results indicate that publicly reported feedback was associated with quality improvement, and the authors suggest that targeted measurement and reporting of process quality may be effective in encouraging improvement in specific areas.
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Content ArticleThis article in Age & Ageing describes a quality improvement project at Leeds Teaching Hospitals Trust (LTHT) that aimed to achieve timely Parkinson’s disease medication administration.
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Content ArticleThe ISMP Targeted Medication Safety Best Practices for Hospitals (TMSBP) were developed to identify, inspire, and mobilise widespread, national adoption in the US of consensus-based best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications. The best practice recommendations presented in this guidance document are based on error reports received through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been reviewed by an external expert advisory panel and approved by the ISMP Board of Trustees. This initiative was first launched in 2014 and is updated with additional best practices, as needed, every two years. While targeted for the hospital-based setting, some best practices are applicable to other healthcare settings. Facilities can focus their medication safety efforts on these Best Practices, which are realistic and have been successfully adopted by numerous organisations.
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Content ArticlePharmacovigilance is the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other medicine/vaccine related problem. This article, published in the journal Drug Safety, outlines how the Egypt Chapter of the International Society of Pharmacovigilance (ISoP) approached raising awareness of the importance of pharmacovigilance and reporting adverse drug reactions during MedSafetyWeek 2020.
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Content ArticleThis article describes the case studies of a 65-year-old woman with a history of acute myeloid lymphoma called her oncology physician's office with symptoms of chemotherapy-induced nausea and a 66-year-old woman was prescribed estradiol vaginal tablets for post-menopausal symptoms. Cynthia Li and Katrina Marquez discuss how both patient cases resulted from human error by pharmacy staff and how although most medication errors can be directly attributed to human error, human error is often a result of poor system design and recommend 'The 8 R's' approach to reduce the risk for errors includes development of safeguards at every level of the medication use process.
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Content ArticleThis webinar is part of Global Patient Safety Webinar Series 2021 and focuses on the third WHO Global Patient Safety Challenge: Medication Without Harm. The webinar presents on overview of the Challenge, technical tools and resources to support its implementation and different approaches to implement the challenge at national, subnational, facility and community levels. A recording of the webinar is available below.
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Content ArticleThis is an analysis of medication errors from January 2018 to December 2019 reported at a university teaching hospital in Riyadh, Saudi Arabia, aimed at identifying whether medication errors are significantly different between day shifts, night shifts, during weekdays and weekends. It found that there was a statistically significant difference between medication errors and day of the week, with a higher number of medication errors happening at the weekend. It also found that during weekends, medication errors were more likely to occur at the night shift compared to the day shift. The authors suggest that timing of medication errors incidence is an important factor to be considered for improving the medication use process and improving patient safety.
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Content ArticleAntimicrobial resistance (AMR) is a global problem that impacts all countries and all people, regardless of their wealth or status. The scale of the AMR threat, and the need to contain and control it, is widely acknowledged by country governments, international agencies, researchers and private companies alike. This document sets out the UK’s 2019–2024 national action plan to tackle AMR within and beyond our own borders. Developed in consultation with a broad range of stakeholders across different sectors, it builds on the achievements of our last strategy (2013–2018), and is aligned with global plans and frameworks for action. The plan has ultimately been designed to ensure progress towards our 20-year vision on AMR, in which resistance is effectively contained and controlled. It focuses on three key ways of tackling AMR: reducing need for, and unintentional exposure to, antimicrobials; optimising use of antimicrobials investing in innovation, supply and access.
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Content Article
Putting patients first in medicines regulation? (30 November 2021)
Sam posted an article in Medication
On 4 July 2021, the Medicines and Healthcare Products Regulatory Agency (MHRA) published its delivery plan for 2021-2023: Putting Patients First: a New Era for our Agency. In this plan, the MHRA promises to make drug regulation in the UK more patient centred, while being “an agile and supportive regulator” to accommodate the interests of the United Kingdom’s life sciences industry. In this BMJ Editorial, Huseyin Naci and colleagues argues that the MHRA’s new delivery plan strikes the wrong note. -
Content ArticleAnticoagulants are used hospital wide throughout the patient trajectory involving many healthcare providers. Given their widespread use and risk profile, they are classified as high risk. Despite the many precautions and vast experience with these drugs, errors often occur in daily practice. The aim of this study was to investigate which factors currently negatively affect patient safety in Az Sint-Lucas hospital in Belgium. The authors performed a retrospective data analysis based on incident reports and registered usage (2018–2019) as well as on pharmaceutical recommendations (3 months period in 2019) related to anticoagulants and antiaggregants. The data were obtained from the hospital information systems. A number of risk factors were identified, such as education of all healthcare professionals, communication, the IT systems used, the opening of temporary wards and transfer of patients within the hospital. It is our opinion that a multidisciplinary, centralised approach with a focus on monitoring is imperative. The use of a clinical pharmacist could play an important role.
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Content Article
Pfizer: Medicine safety tips for patients
Patient Safety Learning posted an article in Medication
Medication errors can happen in clinics and hospitals, pharmacies, and at home. Patients and healthcare providers, however, can work together to help prevent these errors. See Pfizer's tips for patients. -
Content ArticleThis study in BMC Medicine aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings. It is the largest meta-analysis to assess preventable medication harm to date. The authors found that one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Their results support the World Health Organization’s priority of detecting and mitigating medication-related harm and highlight other potential intervention targets that should be a priority research focus.
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Content ArticleThis article in Translational and Clinical Pharmacology aims to highlight the need to reconsider current medication dosing strategies in reproductive women. It uses the example of schizophrenia to illustrate how a woman's clinical symptoms can change throughout the ovulatory cycle, leading to fluctuations in medication responses. The authors found that healthcare professionals need to consider hormonal and clinical changes that occur with the menstrual cycle when prescribing treatments. They also call for further research to increase knowledge of the issues and find better treatment strategies in women whose symptoms change with cyclical changes in ovarian hormones. However, they warn that results from such studies should never override the symptoms and treatment responses experienced by individual clinical patients.
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Content ArticleThis blog by the Institute for Safe Medication Practices identifies ten medication safety concerns in the US from 2021 that still need to be addressed. These concerns are: Mix-ups between the paediatric and adult formulations of the Pfizer-BioNTech COVID-19 vaccines Mix-ups between the COVID-19 vaccines or boosters and the 2021-2022 influenza (flu) vaccines EPINEPHrine administered instead of the COVID-19 vaccine Preparation errors with the Pfizer-BioNTech purple cap or grey cap COVID-19 vaccines Errors and delays with hypertonic sodium chloride Errors with discontinued or paused infusions Infection transmission with shared glucometers, fingerstick devices, and insulin pens Adverse glycaemic event errors Every organisation needs a medication safety officer Increasing error reporting
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Content Article
Blog - Safe medicine saves lives (14 January 2022)
Patient-Safety-Learning posted an article in Medication
In this blog, Roohil Yusuf, Global Pharmacy Advisor at Save the Children, looks at the different factors involved in providing access to life-saving medication, including planning, sourcing, use and management of medicines. She tells the story of Habibah, a three-year-old girl from Nigeria, who was able to access medication for Severe Acute Nutrition and tuberculosis at one of Save the Children's treatment centres. She also looks at the dangers of counterfeit and expired medicines, and explores how organisations can take steps to prevent poor quality, counterfeit or expired medicines being given to patients. -
Content ArticleThis scoping review in JMIR Human Factors looked at existing research into how including the reason for use on a prescription impacts pharmacists. It suggests that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counselling, impact communication and improve patient safety. Concerns about workflow and patient privacy may be factors that prevent the inclusion of use information. The review identified that more research is needed to better understand how the inclusion of use information affects pharmacists.
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Content Article
Medication errors are a leading cause of patient harm globally. WHO launched the Global Patient Safety Challenge: Medication Without Harm, with the objective of preventing severe medication related patient harm globally. This publication is one of the documents in the WHO Technical Series on “Medication Safety Solutions” that the WHO is publishing, to address important aspects pertaining to medication safety.
