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Content ArticleAccording to the World Health Organization (WHO), medication harm accounts for 50% of the overall preventable harm in medical care. As well as telling the story of Melissa Sheldrick, who has been campaigning to improve medication safety since her son Andrew died as a result of a medication error, this blog looks at how making it 'safe-to-say' can reduce the risk of medication errors. Healthcare systems need a culture shift that makes it safe-to-say when something has gone wrong, is going wrong, or could go wrong. The authors argue that it is only when errors are appropriately managed, reported, responded to and learned from that we can improve the system as a whole, support people impacted to heal and take informed action to prevent similar incidents from happening in the future.
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Content ArticleIn the UK, over 26% of adults take prescription medications and in the US the figure is around 66%. But up to 50% of patients fail to take their medications as prescribed. As healthcare steadily pivots towards digital health, Dr. Bertalan Meskó and Dr. Pranavsingh Dhunno ask how new technologies can improve medication management. In this article for The Medical Futurist, they look at the importance of empowering patients to reduce the risk of medication errors. They highlight five medication management technologies that could help patients improve their own medication safety: Smart pill dispensers which deliver audible and visual cues to remind patients to take medications at the right time Medication reminder apps which help manage medication regimens and can sync the data with a caregiver or doctor Digital therapeutics which support patients to make treatment decisions Digital pills which integrate tracking technology into pills themselves Telemedical platforms that allow patients to request advice or raise concerns with their doctors.
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Content ArticleIssues with medication management and errors in medication administration are major threats to patient safety. This article for the US Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network takes a look at the AHRQ's current areas of focus for medication safety. The authors look at evidence-based solutions to improve medication safety in three areas: High-risk medication use and polypharmacy in older adults Reducing opioid overprescribing, increasing naloxone access and use and other interventions for opioid medication safety Nursing-sensitive medication safety The article also explores future research directions in medication safety and highlights that these will advance patient safety overall.
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Content ArticleThe Irish Health Service Executive (HSE) has produced a selection of resources and guidance to help people use medicines safely. It offers information about the Know, Check, Ask campaign, encouraging members of the public to: Know your medicines and keep a list Check that you're using the right medicine the right way Ask your health professional if you're unsure The page also includes videos about: how to use the My medicines list tool designed to ensure patients and healthcare professionals know which medications and doses the patient should be taking. 5 moments for medication safety, a campaign linked to the World Health Organizations' WHO Medsafe app.
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Content ArticleThis document has been produced as part of a project to develop EU guidance for the safe management of hazardous medicinal products (HMPs) at work, including cytotoxins. The project involves the collection of information from key stakeholders across 27 European countries through direct requests, workshops and pilots. The document provides practical guidance on preventing and reducing occupational exposure to HMPs for employers, workers, occupational health and safety (OSH) services and experts, personal training managers and others concerned with advice on the safe management of HMPs at work. The project team is inviting feedback on the draft guidance by 19 September 2022. The guide primarily addresses the following problems: Lack of awareness of HMPs Lack of support tools Unclear definition of HMPs Deficiencies in the flow and/or transfer of information.
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HSE Ireland - My Medicines List leaflet (January 2020)
Patient-Safety-Learning posted an article in Medication
This leaflet produced by the Irish Health Services Executive (HSE) provides a central place for patients to record information about their medications. It acts as a reference point for patients to use when discussing their medications with a healthcare professional and includes a reminder of the Know, Check, Ask campaign, aimed at reducing medication errors in the community. -
Content ArticleThis recording is part of a series of webinars by the Patient Academy for Innovation and Research (PAIR Academy), The International Alliance of Patients’ Organizations (IAPO) and Dakshama Health, to introduce the Strategic Framework of the World Health Organization's Global Patient Safety Challenge - Medication Without Harm. The theme of this sixth webinar is "Medication Safety in Polypharmacy and Transitions of Care."
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Content ArticleNHS Resolution received 172 claims relating to anti-infective medications between 1 April 2015 until 31 March 2020. Anti-infective medications include antibiotics, antivirals and antifungals. The analysis in this leaflet focuses on closed claims that have been settled with damages paid and concern an element of the prescribing process: prescribing, transcribing, dispensing, administering and monitoring. Claims concerning a failure to recognise that an anti-infective was indicated have not been included within the analysis.
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Content ArticleIn this episode of the Driving Insights to Action podcast, patient safety advocates Soojin Jun and Sue Sheridan talk about the role of the World Health Organization's Global Patient Safety Action Plan in helping reduce medication errors in healthcare. They also share their personal experiences of family members' deaths as a result of avoidable harm in healthcare.
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Content ArticleAntimicrobial resistance (AMR) is a major challenge to the UK’s health security, and is already responsible for a significant burden of death, disability and prolonged illness globally. The growing resistance of bacteria, viruses and fungi to the drugs commonly used to treat them threatens modern medicine, and our ability to carry out standard medical procedures. This report draws on the expert input of a roundtable held by public service think tank Reform in October 2022, to assess progress made against proposals published by Reform in 2020.
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Content ArticleClinical trials are the foundation of modern medicine, but regulators, doctors and patients often do not get to see the full picture about how safe and effective drugs and treatments are. The results of around half of all clinical trials remain hidden and there are international efforts to resolve this issue; even government agencies often lack access to the information they need to decide whether treatments are safe and effective. The paper analyses six case studies in which lack of transparency in medical research has directly harmed patients, taxpayers and/or investors. It illustrates how these harms could have been avoided through three simple solutions promoted by the AllTrials campaign: trial registration, results posting, and full disclosure of trial reports.
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Considering Valproate video (February 2022)
Patient-Safety-Learning posted an article in Medication
Sodium valproate is a medication used to treat epilepsy, bipolar disorder and migraines, but it can cause birth defects, learning disabilities and developmental problems in babies if taken during pregmamcy. This video by Central and North West London NHS Foundation Trust discusses the various effects of using valproate, including the potential harmful effects the medication can have on unborn foetuses. It features a conversation between a pharmacist and patient discussing the need for a valproate pregnancy prevention programme if the patient is to be prescribed valproate. -
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AvMA case study: George's story
Patient-Safety-Learning posted an article in Medication
This article tells to story of the events that led to the death of a patient named George from an avoidable medication error in December 2012. George slipped and fell in his garden in October 2012, badly hitting his head. He was taken to hospital where he was diagnosed with a subdural haematoma–when blood collects between the skull and the surface of the brain. After successful life-saving surgery at King’s College Hospital, George was moved to a ward to recover. George suffered from osteoarthritis and had been taking the anti-inflammatory medication naproxen to manage this for some time, accompanied by omeprazole to protect the stomach lining. As he recovered in hospital, he was prescribed his normal naproxen, but was not given the omeprazole to go with it. By the time the hospital stopped the medication, approximately one month later, George had developed severe bleeding and ulcers in his stomach. George’s condition worsened and he died on 4th December 2012. -
Content ArticleThe Australian Institute of Health Innovation conducts world-class research to catalyse health service and systems improvements in Australia and internationally. Its research generates highly practical evidence-based recommendations and information that health services can implement or use now. The Health Innovation Series supports clinicians, hospitals, policy makers and developers to apply this evidence to enhance the health system and services. The Health Innovation Series communicates research evidence in an easy-to-read, short format with clear recommendations, covering a wide range of topics.
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Content ArticleThe National Medication Safety Symposium was held in Sydney, Australia, in support of World Patient Safety Day. The presentations from the 2-day conference can be viewed on YouTube from link below.
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Content ArticleThese reports by the Pharmaceutical Society of Australia look at different aspects of medication safety. Medicine safety: Take care This report details the extent of harms in Australia as a result of medicine use. It highlights that 250,000 Australians are hospitalised each year, with another 400,000 presenting to emergency departments, as a result of medication errors, inappropriate use, misadventure and interactions. At least half of these incidents could have been prevented. Medicine safety: Aged care This report provides data about the real and current medication safety problems affecting older care residents across Australia. Medicine safety: Rural and remote care This report highlights the extreme challenges patients in rural and remote Australia have in accessing health care and the impact that this has on the safe and appropriate use of medicines. Medicine safety: Disability care This report focuses on the challenges that people with disability face in using medicines safely and effectively. The report found that people with disability face challenges at all stages of medicine use–prescribing, dispensing, administration and adherence and monitoring. Medicine safety forum: Informing Australia’s 10th National Health priority area This report presents a summary of views and experiences shared at a stakeholder workshop in December 2019.
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Content ArticleThe World Health Organisation's third World Patient Safety Day took place on 17 September. This year’s theme was medication safety. In this blog, Clare Wade, Assistant Director of Casework at the Parliamentary and Health Service Ombudsman (PHSO) discusses the impact of medication errors and gives examples of poor practice.
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Content ArticleThis dashboard presents the results of a patient safety survey conducted by the European Alliance for Access to Safe Medicines (EAASM) and European Collaborative Action on Medication Errors and Traceability (ECAMET). The dashboard shows variations in different hospital-reported measures of patient safety across thirteen European countries. The questions in the survey focus on accreditation, training, electronic health records and recording, tracking and publishing of medication error data.
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Content ArticlePoor and ambiguous medication recording is a common issue identified by the Care Inspectorate during inspections or complaints activity. This guidance aims to support care staff working in residential care services who record medication administration and develop personal plans, by giving common sense guidance on medication recording and personal plans.
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CPSI: Five questions to ask about your medications
Patient Safety Learning posted an article in Medication
For patients who require multiple medications or who are transitioning between treatments, safety can become a concern. You or your loved one may be at risk of fragmented care, adverse drug reactions, and medication errors. To be an active partner in your health, you need the right information to use your medications safely. The Canadian Patient Safety Institute (CPSI) has teamed up with the Institute for Safe Medication Practices Canada, Patients for Patient Safety Canada, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists to create a list of top questions to help patients and their caregivers have a conversation about medications with their healthcare provider. -
Content ArticleNHS Pharmacy aseptic services in England provide sterile controlled environments for the preparation of injectable medicines into Ready to Administer (RtA) formats for patients. Although not highly visible to patients, £3.84 billion is spent on injectable medicines across the NHS in England each year. Services are subject to high levels of regulatory control and quality assurance. Products include chemotherapy, injectable nutrition and clinical trials for new medicines. This has the potential to release nursing time for care, improve patient safety and support more patient care closer to home. Pharmacy aseptic services are an essential cornerstone of many critical NHS services. They make the chemotherapy that treats cancer patients, the intravenous feed that keeps very sick children and those with intestinal failure alive and the innovative medicines that target complex diseases. The report was commissioned by the Minister of State for Health to provide advice to the government and NHS England and Improvement (NHSE-I), to regional, system, and trust pharmacy leads, as well as independent sector aseptic pharmacy providers.
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Medicines and prescribing are highly risky areas of health care. It is estimated that more than 200 million medication errors occur in NHS every year, and that avoidable adverse drug reactions (ADRs) cause 712 deaths per year, at a financial cost of at least £98.5 million every year.[1] Many medicines and prescribing issues have been highlighted in reports and investigations into patient deaths over the years, yet the issues around prescribing competency are yet to be fully addressed. It is time this omission was rectified. This blog explains why I believe patients, the public and healthcare practitioners, need to be aware of the Prescribing Competency Framework.[2] It outlines why the framework must be applied in practice, used in clinical supervision and CPD, and why we must all speak out of it is not being followed. The benefits of this will include prevention of unnecessary medicines being prescribed, avoidance of drug related harm, and lives saved.- Posted
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Content ArticleThis project includes the design of templates for controlled drugs, Hypnotics/Z-drugs, DMARDs (each orally administered drug has individualized template), NOACs, Warfarin, Lithium and Amiodarone. These templates prompt the user to add compulsory details before the drug can be issued for the first time or for a repeat issue. This has led to better and safer prescribing and potential to identify group of patients who either have not been reviewed or have missed essential monitoring. To avoid visual fatigue templates are short and to the point and a clinician can navigate away by one click if the required fields have been captured recently. Audits of prescribing such drugs has shown better prescribing and more patient involvement in decision making. Read more about this case study on the NICE shared learning database, via the link below.
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Content ArticleThis case study is featured on the National Institute for Health and Care Excellence (NICE) shared learning database. The associated project aims to optimise the safe use of medicines and reduce avoidable harm to patients. Objectives: To ensure prescribers in GP practices identify and report medication related incidents and near misses via the National Reporting and Learning System (NRLS) (Each practice was required to share at least 4 records with the CCG between April 2017 and March 2018) To enable CCG-wide learning opportunities and prevent further incidents in order to improve patient safety across the CCG (Themes and trends will be disseminated at least quarterly through the Prescribing newsletter). To ensure practices responded to patient safety alerts from the MHRA in a timely manner.
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Content ArticleThe Medication Errors Group was established in 2017 under the leadership of Dr Brian Edwards and Professor Ian Wong.. Ensuring the safe and effective use of healthcare products is a key objective for those who work in pharmacovigilance, as well as all other stakeholders, including patients and caregivers. One key element of that is working to reduce and mitigate medication errors and other irrational use of drugs. The mission of the Medication Errors Group is To provide an opportunity for International Society of Pharmacovigilance (ISoP) members, and like-minded collaborators, to network globally in a professional and neutral environment, to share evidence and solutions that can ideally eliminate and/or at least reduce the number and severity of medication errors. This will enable continuous improvement in the use of medicines whilst supporting the interests of patients and their families, and healthcare professionals.
