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Home > Pharmacist > Medication Errors

Medication Errors

Responding to complaints and concerns
General Pharmaceutical Council

This guidance sets out what owners and superintendents of a body corporate should consider when minimising the risk of dispensing errors and what to do if a dispensing error is made. It also gives guidance on dealing with complaints and concerns raised by patients, the public and other healthcare professionals.

Source: pharmacyregulation.org
Pharmacy Resource: Guidance
Register to Access Content: No

Last Checked: 26/09/17 Link Error: Report It

 

Recommendations to Enhance Accuracy of Dispensing Medications
National Coordinating Council for Medication Error Reporting and Prevention

Source: nccmerp.org
Pharmacy Resource: Recommendations
Register to Access Content: No

Last Checked: 19/10/15 Last Checked: Report It

 

Reducing Medication Errors Associated with At-risk Behaviors by Healthcare Professionals
National Coordinating Council for Medication Error Reporting and Prevention

Source: nccmerp.org
Pharmacy Resource: Recommendations
Register to Access Content: No

Last Checked: 19/05/15 Last Checked: Report It

 

Royal Pharmaceutical Society Guide: Near Miss Errors

This guidance is for superintendents, pharmacy owners, pharmacists and pharmacy staff.

Our near miss error log and near miss error improvement tool, along with supporting guidance, can help you and your pharmacy team to work through the near miss errors (NMEs) and learn from them.

Source: rpharms.com
Pharmacy Resource: Guide and Error Log Sheet
Register to Access Content: Yes - content available to members of the RPS

Last Checked: 26/02/14 Link Error: Report It

 

Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe study
A report for the GMC

The report makes a number of recommendations for improving the safety of prescribing including:

  • Promoting the effective use of clinical computer systems for safe prescribing.
  • Increasing the prominence given to therapeutic knowledge and the skills and attitudes needed for safe prescribing during GP training.
  • Promoting the reporting of adverse prescribing events (and near misses) through national reporting systems.

In addition, the research suggests that pharmacists can play a greater role in mitigating the occurrence of error, through reviewing patients with complex medicines regimens at a practice level, and in identifying and informing the GP of errors at the point of dispensing.

Source: gmc-uk.org
Pharmacy Resource: Report
Register to Access Content: No

Last Checked: 17/08/15 Link Error: Report It

 

PRACTICE: the prevalence and causes of prescribing errors

Steve Chaplin provides details of one of the largest UK studies into the prevalence and causes of prescribing errors in primary care.

Source: eu.wiley.com
Pharmacy Resource: Journal Article
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Design for patient safety: a guide to the design of dispensed medicines

This booklet explores how design can be used to make dispensed products safer for patients, whether they are dispensed from community pharmacies, doctor dispensing practices or hospital pharmacies.

Organisations, managers and healthcare workers involved in dispensing medicines should use this booklet as a resource to help introduce new initiatives to minimise harm from medicines.

It looks at some key elements of dispensed medicines, including:

  • setting up a label, including label size, font, layout and paper quality;
  • applying dispensing labels to medicines; and
  • auxiliary aids to help patients use medicines.
Source: npsa.nhs.uk
Pharmacy Resource: Guidance
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Design for patient safety: a guide to the design of the dispensing environment

This booklet shows how the design of the dispensing environment can make the dispensing process safer in community pharmacies, dispensing doctor practices and hospital pharmacies.

By breaking the dispensing process down into its constituent parts, each stage can be looked at individually and improved design applied to each one to make the process as safe as possible. This booklet looks at each stage in more detail.

Among the suggestions in the guide are:

  • how changes to the general dispensing environment can improve patient safety;
  • and how design changes to the stages of dispensing a prescription can help reduce errors.
Source: npsa.nhs.uk
Pharmacy Resource: Guidance
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Last Checked: 06/11/13 Link Error: Report It

 

Design for patient safety: A guide to the graphic design of medication packaging

It is estimated that a third of medication errors in the NHS are caused by confusion over packaging and labelling instructions. Improvements to the design of medicine packaging could therefore help to reduce this figure whilst also increasing medication compliance.

Design for patient safety: A guide to the graphic design of medication packaging shows how graphic design on medicine packaging can enhance patient safety and details best practice based on established guidelines. It focuses on:

  • Blister packs - the most common type of primary packaging for prescription medicines
  • Secondary packaging used to contain blister packs
  • The label attached to secondary packaging in pharmacies.

The document is aimed at packaging designers and pharmaceutical companies, but will also be of interest to those in the NHS who regulate and purchase medication.

Source: npsa.nhs.uk
Pharmacy Resource: Guidance
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Best Practice Guidance on The Labelling and Packaging of Medicines
Medicines and Healthcare Products Regulatory Agency

As part of a move towards an increase in self regulation of medicines labelling and packaging, this document has been developed to aid those responsible for the origination of labelling and packaging artwork. It sets out the legal framework for labelling and packaging as described in UK and EU legislation. In addition it describes best practice in the area of labelling and packaging to ensure that medicines can be used safely by all patients, the public and healthcare professionals alike. It also reflects the expectations of healthcare professionals, patients and regulators with respect to reduction in medication errors, and safe selection and use of medicines by all users

Source: gov.uk/mhra
Pharmacy Resource: Guidance
Register to Access Content: No

Last Checked: 23/02/15 Link Error: Report It

 

Position Statement: Making Medicines Naming, Labeling and Packaging Safer

In many countries the regulation of medicines naming, labelling and packaging is not providing adequate safeguards for patients. The International Medication Safety Network issues recommendations to regulators, pharmaceutical industry and healthcare providers as part of a comprehensive, worldwide solution to the problem of unsafe medicines naming, labeling and packaging.

Source: intmedsafe.net
Pharmacy Resource: Position Statement
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Last Checked: 31/07/14 Link Error: Report It

 

Design for patient safety: guidelines for the safe on-screen display of medication information

This booklet provides guidance to Healthcare Information Technology (HIT) vendors, those procuring HIT software, and patient safety and risk management professionals with recommendations for the safe on-screen display of medicines information.

The issues and recommendations demonstrate how to avoid misinterpretation of electronic prescriptions. They address known errors identified from both handwritten and electronic prescriptions, and suggest ways in which these can be avoided in the future.

Source: npsa.nhs.uk
Pharmacy Resource: Guidance
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

 

Safety in doses

Reports of patient safety incidents relating to medication can help inform the action required by the NHS to improve safety for patients.

The National Reporting and Learning Service (NRLS) regularly reviews the incidents reported from the NHS in England and Wales. The NRLS has published two reports that set out the analysis of these reports and aim to help ensure that medicines are used safely and prevent similar incidents from happening again.

Safety in Doses: improving the use of medicines in the NHS has been published in 2007 and in 2009. The reports identify risks and areas for action.

Source: npsa.nhs.uk
Pharmacy Resource: Data Report
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

The Contribution of Pharmacy to making Britain a Safer Place to Take Medicines

The Royal Pharmaceutical Society of great Britain (RPSGB) is the professional and regulatory body for pharmacists in England, Scotland and Wales. Hemant Patel, a former President of the RPSGB, set out an ambition to establish Britain as the safest place in the world to receive medicines (Royal Pharmaceutical Society 2007). This report, commissioned by the RPSGB, is intended to be a step towards fulfilling this vision. It examines the current state of knowledge about medication safety in the UK and considers the role of the RPSGB, the future professional body for pharmacy (following the RPSGB’s demerger into separate regulatory and professional bodies in 2010) and of pharmacists working across Great Britain in improving medicines safety.

Source: wppf.org
Pharmacy Resource: Report
Register to Access Content: No

Last Checked: 17/08/15 Link Error: Report It

 

Patient Safety: Maximising Patient Safety in Europe through the safe use of medicines
Pharmaceutical Group of the European Union

Dispensing the appropriate medicine and providing the relevant information and care, to the right person, at the right time is central in the community pharmacist's daily practice, but many other actions of our daily practice are one way or another linked to Patient Safety. That is why it is not possible to identify single initiatives towards ensuring Patient Safety in community pharmacies without contextualizing them in the community pharmacy setting, the distribution chain and the continuum of care.

Source: pgeu.eu
Pharmacy Resource: Policy Statement
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Last Checked: 06/11/13 Link Error: Report It

 

Creation of a better medication safety culture in Europe: Building up safe medication practices

The Council of Europe Committee of Experts on Pharmaceutical Questions established the Expert Group on Safe Medication Practices in 2003 to review medication safety and to prepare recommendations to specifically prevent adverse events caused by medication errors in European health care.

This report essentially deals with medication errors and their prevention. It presents the work carried out by the Expert Group on Safe Medication Practices and represents the first international report on this topic with a special focus on Europe.

Source: edqm.eu
Pharmacy Resource: Report
Register to Access Content: No

Last Checked: 19/10/15 Link Error: Report It

 

Drug Safety Update
Medicines and Healthcare Products Regulatory Agency

Source: gov.uk/mhra
Pharmacy Resource: Publication
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Last Checked: 23/02/15 Link Error: Report It

 

Institute for Safe Medication Practices (ISMP) Canada Safety Bulletins

The Institute for Safe Medication Practices Canada is an independent national not-for-profit organization committed to the advancement of medication safety in all healthcare settings.

Source: ismp-canada.org
Pharmacy Resource: Bulletins
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Last Checked: 06/11/13 Link Error: Report It

 

Medication Safety

Medication Safety is a series of articles that are published in the Journal of Pharmacy Practice and Research. They provide up-to-date information about medication safety issues and strategies to prevent medication errors. The incidents reported are drawn from Australian experience and from the Institute for Safe Medication Practices (ISMP), USA.

Source: shpa.org.au
Pharmacy Resource: Journal Articles
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Last Checked: 06/11/13 Link Error: Report It

 

Building a Safer NHS for Patients: Improving Medication Safety

Errors occur in the prescribing, dispensing and administration of medicines. They can have serious consequences and they are invariably preventable. This report explores the causes and frequency of medication errors, highlights drugs and clinical settings that carry particular risks, and identifies models of good practice to reduce risk.

Source: webarchive.nationalarchives.gov.uk
Pharmacy Resource: Report
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Last Checked: 06/11/13 Link Error: Report It

 

Patient safety: an introduction

After completing this module, you should be able to:

  • Understand the importance of patient safety
  • Understand how errors may happen
  • Know what strategies are available to reduce the likelihood of errors
  • Understand the clinician's responsibilities in ensuring patient safety.
Source: learning.bmj.com
Pharmacy Resource: CPD / CME / Learning
Register to Access Content: Yes - Registration is FREE

Last Checked: 06/11/13 Link Error: Report It

 

CPPE
Improving medicines safety

Learning objectives: On completion of all aspects of this programme you should be able to:

  • Define what is meant by a medication incident
  • Describe the development of patient safety priorities and the role of medicines governance in healthcare
  • Promote the reporting and investigating of medication incidents as a means to improving patient safety
  • Identify potential sources of medication incidents that can occur
  • List commonly use high-risk medicines
  • Develop strategies to reduce the occurrence of medication incidents in your practice
Source: cppe.ac.uk
Pharmacy Resource: CE / CPD / Learning
Register to Access Content: Yes

Last Checked: 06/11/13 Link Error: Report It

 

CPPE
Making a difference: Preventing medication errors in the community and primary care

Learning objectives: On completion of all aspects of this learning programme you should be able to:

  • discuss the background to the PINCER and PRACtICe studies
  • list the main results and recommendations of the PINCER and PRACtICe studies
  • identify three ways in which pharmacists can intervene or have intervened to prevent, limit or minimise the effects of prescribing errors
  • discuss with your colleagues how to produce better outcomes for your patients from the interventions you make
Source: cppe.ac.uk
Pharmacy Resource: CE / CPD / Learning
Register to Access Content: Yes

Last Checked: 06/11/13 Link Error: Report It

 

American Society of Health-System Pharmacists Guidelines on Preventing Medication Errors in Hospitals

This document suggests medication error prevention approaches that should be considered in the development of organizational systems and discusses methods of managing medication errors once they have occurred. These guidelines are primarily intended to apply to the inpatient hospital setting because of the special collaborative processes established in the setting [e.g., formulary system, pharmacy and therapeutics (P&T) committee, and opportunity for increased interaction among health-care providers].

Source: ashp.org
Pharmacy Resource: Guideline
Register to Access Content: No

Last Checked: 06/11/13 Last Checked: Report It

 

CPPE
Making a difference: Preventing medication errors in hospitals

Learning objectives: After listening to the podcast and completing your workbook, you should be able to:

  • discuss the background to the EQUIP study list the main results and recommendations of the EQUIP studyi
  • identify three ways in which pharmacists can intervene or have intervened to prevent, limit or minimise the effects of prescribing errors
  • discuss with your colleagues how to produce better outcomes for your patients from the interventions you make
  • explain how you plan to extend your interventions to improve patient outcomes
Source: cppe.ac.uk
Pharmacy Resource: CE / CPD / Learning
Register to Access Content: Yes

Last Checked: 06/11/13 Link Error: Report It

 

British Pharmacological Society Ten Principles of Good Prescribing

Prescribing is the main approach to the treatment and prevention of disease in modern healthcare. While medicines have the capacity to enhance health, all have the potential to cause harm if used inappropriately. For these reasons the British Pharmacological Society recommends that healthcare professionals who prescribe medicines should do so based on the following ten principles, which underpin safe and effective use of medicines.

Source: bps.ac.uk
Pharmacy Resource: Guideline
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Improving safety & managing risk in medicines management systems and processes

‘Increasing safety and managing risk in medicines management systems and processes’ incorporates;

  • Reducing risk and
  • Reducing medication errors

Find out more information about ‘Increasing safety and managing risk in medicines management systems and processes’ by using the eLearning materials for reducing risk, and ‘reducing medication errors’ and/or the other available links and resources situated on the left-hand side menu.

Source: webarchive.org.uk
Pharmacy Resource: e-Learning
Register to Access Content: No

Last Checked: 23/04/15 Link Error: Report It

 

The Use of Tall Man Lettering to Minimise Selection Errors of Medicine Names in Computer Prescribing and Dispensing Systems

One source of potential error in prescribing is to mistake the required medicine name for another similar sounding or looking name. So called ‘look-alike, sound-alike’ medicine combinations are presented to Health Care Practitioners (HCPs) by computer-based prescribing and dispensing systems, and may predispose selection error. Approaches to try to prevent this happening include the use of ‘Tall Man’ lettering. This is where some letters of the medicine’s name, which is presented in lowercase font, possibly with the initial letter capitalised for a brand name, are capitalised.

Source: webarchive.nationalarchives.gov.uk
Pharmacy Resource: Report
Register to Access Content: No

Last Checked: 18/08/15 Link Error: Report It

 

National list of Australian medicines names with Tall Man applied

This list has been compiled to include look-alike, sound-alike names that have been predicted to pose the greatest risks to patient safety. The overall risk rating is a combination of measures that estimate the likelihood that the medicines names and associated products will be confused and the overall patient harm that may occur if this confusion occurred.

Source: safetyandquality.gov.au
Pharmacy Resource: List
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters

The sets of look-alike drug names in this tool have been modified using “tall man” letters to help draw attention to the dissimilarities in their names.

Source: ismp.org
Pharmacy Resource: Lists
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Last Checked: 06/11/13 Link Error: Report It

 

Reducing prescribing errors

This evidence scan examines strategies to reduce prescribing errors.

The scan provides a rapid collation of empirical research about initiatives to reduce prescribing errors. It addresses the following questions:

  • What approaches have been used to reduce prescribing errors?
  • Have any approaches related to human factors been researched?

The scan finds that most studies about reducing prescribing errors have been undertaken in hospital. The three most commonly researched approaches are, in order of frequency: computerised tools, training to improve prescribing and expanding professional roles to identify errors.

Source: health.org.uk
Pharmacy Resource: Evidence Scan
Register to Access Content: No

Last Checked: 17/08/15 Link Error: Report It

 

“Part 1: Medication Error Prevention Update”

This is our biannual lesson on “Medication Errors.” It’s been divided into two portions. In this lesson we describe the outdated culture of punishment. Additionally, we discuss Root Cause Analysis & take a look at a couple of cases involving drug errors.

“Part 2: Medication Error Prevention Update”

This is our biannual lesson on “Medication Errors.” It’s been divided into two portions. This is Part 2, and we review techniques & considerations for lessening medication errors. We build on the principles discussed in Part 1.

Source: wfprofessional.com
Pharmacy Resource: CE / CPD / Learning
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Medication errors

Medication errors, broadly defined as any error in the prescribing, dispensing, or administration of a drug, irrespective of whether such errors lead to adverse consequences or not, are the single most preventable cause of patient harm. Medication errors may be classified according to the stage of the medication use cycle in which they occur (prescribing, dispensing, or administration) although a recent classification of medication error into mistakes, slips, or lapses has been proposed.

Source: rcpe.ac.uk
Pharmacy Resource: Journal Article
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Prescribing Errors
What’s the Story?

This paper reviews what is currently known about prescribing errors. It is suggested that prescribing errors occur in at least 1-2% of all medication orders written, cause harm in about 1% of admissions, and have a wide range of causes.

Source: mcppnet.org
Pharmacy Resource: Journal Article
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Prescribing Errors

At the completion of this article, the reader should be able to:

  1. Identify the incidence of prescribing errors in various care settings
  2. Recognize the types of prescribing errors reported most commonly in the literature
  3. List the interventions that have been recommended for reducing prescribing errors during hospital care, ambulatory care, and long-term care
  4. State the opportunities for pharmacists to reduce medication errors in hospitals
  5. Recognize potential barriers to reducing medication errors
Source: cshp.org
Pharmacy Resource: Journal Article
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Learning from prescribing errors

This paper focuses on prescribing errors and argues that, while learning from prescribing errors is a laudable goal, there are currently barriers that can prevent this occurring. Learning from errors can take place on an individual level, at a team level, and across an organisation.

Source: nih.gov
Pharmacy Resource: Journal Article
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Avoidable prescribing errors: incidence and the causes

In the first of two articles looking at how to reduce prescription errors in general practice, Professor Tony Avery discusses their incidence and the underlying causes.

Avoidable prescribing errors: communication and monitoring

In the second of two articles looking at how to reduce prescription errors in general practice, Professor Tony Avery discusses communication, medication monitoring and repeat prescribing.

Source: eu.wiley.com
Pharmacy Resource: Journal Articles
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Learning from Error - video and booklet

This video was produced for use in a seminar or workshop setting in conjunction with the Learning from Error booklet. The booklet explains more about how the resource can be used to facilitate learning for health care professionals.

Chapter 1 provides an introduction to the concept of root cause analysis. Chapter 2 is a dramatized incident of how a series of errors led to the incorrect administration of vincristine. Chapters 3-8 analyse the drama in the light of five factors that can reduce error in health care.

Source: who.int
Pharmacy Resource: Video and Booklet
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Medication Errors

Medication errors, defined as any error in the prescribing, dispensing or administration of a drug whether there are adverse consequences or not, are the single most preventable cause of patient injury. These errors can occur at any stage in the drug use process from prescribing to administration to the patient.

Source: stjames.ie
Pharmacy Resource: Medicines Information Centre Bulletin
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

The pathophysiology of medication errors: how and where they arise

In this review we consider how errors can occur and what factors alter the risk of error.

Source: eu.wiley.com
Pharmacy Resource: Journal Article
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Pharmacy Intervention in the Medication-use Process
the role of pharmacists in improving patient safety

As highlighted in a report produced in November 2009 "Pharmacy Intervention in the Medication-use Process - the role of pharmacists in improving patient safety", the involvement of pharmacists in patient safety can be as early at the prescribing phase and up to the administration of the medicines. In many cases, pharmacists are supported by programmes and activities from their national associations, as listed in this extensive work completed by Advit Shah, a final year pharmacy student from the University of Manitoba in Winnipeg, Canada, through an internship at FIP focusing on Patient Safety.

Source: fip.org
Pharmacy Resource: Report
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Last Checked: 06/11/13 Link Error: Report It

 

Health Literacy: Statistics At-A-Glance

Research shows that most consumers need help understanding health care information; regardless of reading level, patients prefer medical information that is easy to read and understand. For people who don’t have strong reading skills, however, easy-to-read health care materials are essential.

Source: npsf.org
Pharmacy Resource: Factsheet
Register to Access Content: No

Last Checked: 04/11/14 Last Checked: Report It

 

 

Keeping patients safe when they transfer between care providers – getting the medicines right
Final Report
Royal Pharmaceutical Society

Source: rpharms.com
Pharmacy Resource: Report
Register to Access Content: No

Last Checked: 03/04/17 Link Error: Report It

 

National Institute for Health and Care Excellence (NICE) Guidance > Managing medicines in care homes

This guideline covers good practice for managing medicines in care homes. It aims to promote the safe and effective use of medicines in care homes by advising on processes for prescribing, handling and administering medicines. It also recommends how care and services relating to medicines should be provided to people living in care homes.

Source: nice.org.uk
Pharmacy Resource: Guidance
Register to Access Content: No

Last Checked: 13/11/17 Link Error: Report It

 

National Institute for Health and Care Excellence (NICE) Guidance > Managing medicines for adults receiving social care in the community

This guideline covers medicines support for adults (aged 18 and over) who are receiving social care in the community. It aims to ensure that people who receive social care are supported to take and look after their medicines effectively and safely at home. It gives advice on assessing if people need help with managing their medicines, who should provide medicines support and how health and social care staff should work together.

Source: nice.org.uk
Pharmacy Resource: Guidance
Register to Access Content: No

Last Checked: 13/11/17 Link Error: Report It

 

The ‘How to Guide’ for Reducing Harm from High Risk Medicines

This document is aimed at team members involved in implementing changes to reduce harm from high risk medicines. It may also provide a useful overview for the following:

  • Relevant service managers
  • Senior managers/executives supporting the work and monitoring its progress
  • Service improvement personnel who may be required to provide improvement or change management expertise in relation to the work.

The report finds that the medicines most frequently associated with severe harm were:

  • Anticoagulants
  • Antibiotics (allergy related)
  • Injectable sedatives
  • Chemotherapy
  • Opiates
  • Antipsychotics
  • Insulin
  • Infusion fluid
Source: patientsafetyfirst.nhs.uk
Pharmacy Resource: Guide
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Institute for Safe Medication Practices (ISMP) High-Alert Medications

High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. Use these lists to determine which medications require special safeguards at your practice site to reduce the risk of errors.

  • Institutional and Inpatient Healthcare Settings
  • Community and Ambulatory Healthcare Settings
Source: ismp.org
Pharmacy Resource: Lists
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

SafeRx - Safe Use of High Risk Medicines

Bulletins Menu

Source: saferx.co.nz
Pharmacy Resource: Bulletins
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Safety indicators for inpatient and outpatient oral anticoagulant care
Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency

The target audience for this guideline is healthcare professionals involved in the management of patients receiving oral anticoagulant therapy

Source: bcshguidelines.com
Pharmacy Resource: Guideline
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

The adult patient’s passport to safer use of insulin

The aim of this Alert is to improve patient safety by empowering patients as they take an active role in their treatment with insulin.

This will be achieved with a patient information booklet and a patient-held record (the Insulin Passport) which documents the patient’s current insulin products and enables a safety check for prescribing, dispensing and administration. The Insulin Passport will complement existing systems for ensuring key information is accessed across healthcare sectors.

The adult patient’s passport to safer use of insulin
The adult patient’s passport to safer use of insulin supporting information
Insulin passport contents
Insulin patient information booklet

Source: npsa.nhs.uk
Pharmacy Resource: Alert
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

NHS Diabetes

Welcome to the Healthcare e-Academy and the NHS IQ Insulin Safety Suite of e-learning modules.

  • The Safe Use of Insulin
  • The Safe Use of Intravenous Insulin Infusions
  • The Safe Use of Non-Insulin Therapies for Diabetes
  • The Safe Management of Hypoglycaemia
Source: nhsdiabetes.healthcareea.co.uk
Pharmacy Resource: e-Learning Modules
Register to Access Content: Yes

Last Checked: 06/11/13 Link Error: Report It

 

Insulin Safety

This bulletin focuses on errors involving insulin and practical advice - to all staff involved in prescribing, dispensing or administration of insulin – to improve insulin safety.

Source: ggcprescribing.org.uk
Pharmacy Resource: Bulletin
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Reducing dosing errors with opioid medicines

This Rapid Response Report alerts all healthcare professionals prescribing, dispensing or administering opioid medicines to the risks of patients receiving unsafe doses.

Source: npsa.nhs.uk
Pharmacy Resource: Alert
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Safe use of opioids

This edition has been produced as feedback to medical, nursing and pharmacy staff about safe use of opioids following incidents reported on Datix.

Source: ggcprescribing.org.uk
Pharmacy Resource: Bulletin
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Medication incidents related to the use of fentanyl transdermal systems: An international aggregate analysis
International Medication Safety Network

Over the past several years, there have been reports in the medical literature and from medication safety centres around the world concerning adverse events with fentanyl transdermal systems (also referred to as fentanyl “patches”). Many of these incidents have been reported to result in harm and in some cases, even death.

Source: intmedsafe.net
Pharmacy Resource: Report
Register to Access Content: No

Last Checked: 31/07/14 Link Error: Report It

 

Inappropriate Prescribing of Fentanyl Patches Is Still Causing Alarming Safety Problems

Despite warnings from the FDA, drug manufacturers, and patient safety agencies, fentanyl transdermal patches continue to be prescribed inappropriately to treat acute pain in opioid naive patients, sometimes in large doses or in combination with oral or intravenous (IV) opioids.

Source: nih.gov
Pharmacy Resource: Journal Article
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Last Checked: 06/11/13 Link Error: Report It

 

Reducing treatment dose errors with low molecular weight heparins

Prescribed doses of low molecular weight heparins (LMWHs) for the treatment of a thromboembolic event are dependent on the weight of the patient and renal function. Underdosing has an increased risk of a further thromboembolic event, while overdosing can increase the risk of bleeding.

Source: npsa.nhs.uk
Pharmacy Resource: Alert
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Last Checked: 06/11/13 Link Error: Report It

 

Getting the right medication | Epilepsy Society

We have produced a letter signed by our medical director Professor Ley Sander, supporting your right to be prescribed the same version of your AEDs - unless of course a change is advised for medical reasons. You can download the letter below and give it to your GP, neurologist, pharmacist or healthcare professional. This will help to explain why consistency of medication is important.

Source: epilepsysociety.org.uk
Pharmacy Resource: Letter
Register to Access Content: No

Last Checked: 06/11/13 Link Error: Report It

 

Antiepileptics: changing products

This section of the website provides information about switching between manufacturers’ products of antiepileptic drugs, including switching between branded products and generic products, and between different generic products of a particular drug.

Source: webarchive.nationalarchives.gov.uk
Pharmacy Resource: Various
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Last Checked: 23/02/15 Link Error: Report It

 

Patient safety failures in asthma care: the scale of unsafe prescribing in the UK 

Last year’s National Review of Asthma Deaths highlighted prescribing errors in nearly half of asthma deaths in primary care (47%). Asthma UK has subsequently analysed data from over 500 UK GP practices which shows these prescribing errors were just the tip of the iceberg.

Our analysis reveals there is evidence that over 22,000 people with asthma in the UK, including 2,000 children, have been prescribed medicines (long-acting reliever inhalers) in a way that is so unsafe they have a ‘black box warning’ in the USA due to the risk they pose to the lives of people with asthma. Our report also indicates that almost 100,000 people with asthma have been prescribed too many short-acting reliever inhalers (more than 12 in a year) without national clinical guidelines being followed, leaving them at risk of life threatening asthma attacks.

Source: asthma.org.uk
Pharmacy Resource: Report
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Last Checked: 25/06/15 Link Error: Report It

 

American Society of Health-System Pharmacists Guidelines on Preventing Medication Errors with Antineoplastic Agents

The purpose of these guidelines is to assist practitioners in improving their antineoplastic medication-use system and error-prevention programs.

Source: ashp.org
Pharmacy Resource: Guideline
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Last Checked: 06/11/13 Last Checked: Report It

 

Improving compliance with oral methotrexate guidelines

This Patient Safety Alert reissues guidance to the NHS in England and Wales to reduce the risk of patient harm associated with the incorrect dosing frequency of oral methotrexate.

Improving compliance with oral methotrexate guidelines - Patient Safety Alert
Making sure you take oral methotrexate safely- Patient Briefing
Oral methotrexate tablets - IT requirement specification
Oral methotrexate patient information leaflet & dosage record booklet
Towards the safer use of oral methotrexate

Source: npsa.nhs.uk
Pharmacy Resource: Alert
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Last Checked: 06/11/13 Link Error: Report It

 

ESPRIT Ciclosporin-Specific Resources

Following the introduction of alternative formulations of ciclosporin into the UK, please find below some materials that will help to communicate the potential complications that could result if a patient were inadvertently switched between ciclosporin brands.

Source: esprit.org.uk
Pharmacy Resource: Various
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Last Checked: 02/06/15 Link Error: Report It

 

ESPRIT Tacrolimus-Specific Resources

Following the introduction of alternative formulations of tacrolimus into the UK, please find below some materials that will help to communicate the potential complications that could result if a patient were inadvertently switched between tacrolimus brands.

Source: esprit.org.uk
Pharmacy Resource: Poster
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Last Checked: 02/06/15 Link Error: Report It

 

Preventing fatalities from medication loading doses

A loading dose is an initial large dose of a medicine used to ensure a quick therapeutic response. It is usually given for a short period before therapy continues with a lower maintenance dose. The use of loading doses of medicines can be complex and error prone. Incorrect use of loading doses or subsequent maintenance regimens may lead to severe harm or death.

Preventing fatalities from medication loading doses
Preventing fatalities from medication loading doses supporting information

Source: npsa.nhs.uk
Pharmacy Resource: Alert
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Last Checked: 06/11/13 Link Error: Report It

 

Safety First Alert
Massachusetts Coalition for the Prevention of Medical Errors

Wrong-Route Errors

Improving Prescription/Order Writing

Errors in Transcribing and Administering Medications

Look-Alike/Sound-Alike Medication Errors

Source: macoalition.org
Pharmacy Resource: Publication
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Last Checked: 06/11/13 Link Error: Report It

 

Recommendations for Terminology, Abbreviations and Symbols used in the Prescribing and Administration of Medicines

Source: safetyandquality.gov.au
Pharmacy Resource: Publication
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Last Checked: 06/11/13 Link Error: Report It

 

Drug names that look & sound alike

Listed below are some drug names that can look and/or sound alike. Some are dangerously close, whereas others require incomplete prescribing information, poor communication skills, poor listening, and/or a lack of knowledge about the drugs for an error to result.

Source: derbyhospitals.nhs.uk
Pharmacy Resource: List
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Last Checked: 06/11/13 Link Error: Report It

 

ISMP Confused Drug Name List

Drug names that have been mistaken for one another, including look-alike and sound-alike name pairs.

Source: ismp.org
Pharmacy Resource: List
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Last Checked: 06/11/13 Link Error: Report It

 

Compiled list of confusable Australian drug names

Source: safetyandquality.gov.au
Pharmacy Resource: List
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Last Checked: 06/11/13 Link Error: Report It

 

Look-alike, Sound-alike Drug Names

Reducing medical errors has become a priority in health care today. One area of potential prescribing error is confusing one medication for another that is spelled or sounds similar to a different medication. Below is a listing of "Look-alike, Sound-alike Drug Names" that should be prescribed with care.

Source: edrugbook.com
Pharmacy Resource: List
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Last Checked: 06/11/13 Link Error: Report It

 

Similar names severity risk scores

Source: safetyandquality.gov.au
Pharmacy Resource: Table
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Last Checked: 06/11/13 Link Error: Report It

 

Look-Alike, Sound-Alike Medication Names

The existence of confusing drug names is one of the most common causes of medication error and is of concern worldwide. With tens of thousands of drugs currently on the market, the potential for error due to confusing drug names is significant.

Source: who.int
Pharmacy Resource: Publication
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Last Checked: 06/11/13 Link Error: Report It

 

Standards for the design of hospital in-patient prescription charts

A report prepared for Sir Bruce Keogh, NHS Medical Director, from the Academy of Medical Royal Colleges in collaboration with the Royal Pharmaceutical Society and Royal College of Nursing Terms of reference.

Source: aomrc.org.uk
Pharmacy Resource: Report
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Last Checked: 30/04/14 Link Error: Report It

 

An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study.

This programme of research aimed to explore the causes of prescribing errors made by first year foundation trainee (FY1) doctors, concentrating on the interplay between their educational backgrounds and factors in their practice environments. It aimed also to arrive at evidence-based recommendations to improve patient safety and define a future research agenda.

Source: gmc-uk.org
Pharmacy Resource: Report
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Last Checked: 17/08/15 Link Error: Report It

 

Writing safe and effective prescriptions in a hospital kardex

This brief review highlights important principles and rules that support safe and effective prescribing in hospitals. It was first published as part of this College’s CME online module on Clinical Pharmacology.

Source: rcpe.ac.uk
Pharmacy Resource: Journal Article
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Last Checked: 06/11/13 Link Error: Report It

 

National Institute for Health and Care Excellence (NICE) Guidance > Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes

This guideline covers safe and effective use of medicines in health and social care for people taking 1 or more medicines. It aims to ensure that medicines provide the greatest possible benefit to people by encouraging medicines reconciliation, medication review, and the use of patient decision aids.

Source: nice.org.uk
Pharmacy Resource: Guidance
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Last Checked: 13/11/17 Link Error: Report It

 

Medication Reconciliation: A Learning Guide

After completing this module, healthcare providers will be able to explain:

  • the concept of medication reconciliation
  • why medication reconciliation is important for patient safety
  • the components needed to perform a complete and accurate medication history
  • the process of reconciling medications on admission, transfer or discharge of the patient
  • the role of each team member in medication reconciliation
  • the role of the patient, family members, and other healthcare workers in medication reconciliation
Source: queensu.ca
Pharmacy Resource: Module
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Last Checked: 06/11/13 Link Error: Report It

 

e-BPMH Training Package

Medication Reconciliation is a patient safety initiative that aims to minimize adverse events experienced by patients as they make transitions within the healthcare system. The Best Possible Medication History (BPMH) consists of an accurate list of all medications a patient takes at home and, therefore, serves as the foundation for subsequent medication orders. As a result, the acquisition of the BPMH constitutes a vital step in the Medication Reconciliation process.

Source: sunnybrook.ca
Pharmacy Resource: Training Package
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Last Checked: 06/11/13 Link Error: Report It

 

Medicine Reconciliation
A Practice Guide

Source: webarchive.org.uk
Pharmacy Resource: Guideline
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Last Checked: 15/11/17 Link Error: Report It

 

Get it right! Taking a Best Possible Medication History training video

Medication reconciliation is a formal process of obtaining and verifying a complete and accurate list of each patient’s current medicines.

Source: safetyandquality.gov.au
Pharmacy Resource: Video
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Last Checked: 06/11/13 Link Error: Report It

 

CPPE
Medicines reconciliation - learning@lunch module

Overview: The purpose of this programme is to support pharmacists and pharmacy technicians in taking a structured approach to reconciling medicines for patients in the acute setting.

It focuses on the reconciliation of medicines within 24 hours for patients who are admitted to acute (and mental health) trusts, as required by NICE guidance.

Source: cppe.ac.uk
Pharmacy Resource: CE / CPD / Learning
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Last Checked: 06/11/13 Link Error: Report It

 

Medication errors: the importance of an accurate drug history

Error is possible in any part of the medication process – prescribing, transcription, dispensing, administration, or monitoring – but it is in the prescribing phase that errors in the medication history may have their effect.

Source: eu.wiley.com
Pharmacy Resource: Journal Article
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Last Checked: 06/11/13 Link Error: Report It

 

Safety of Medicines in Care Homes
National Care Forum

A comprehensive resource pack has been developed to enable care service providers to improve medicines management, help residents to understand their rights, and to develop safer working practices so that medicines are administered more safely and drug errors are reduced.

A partnership was formed to try and address some of the issues raised by the Care Homes’ Use of Medicines Study (CHUMS) and ongoing concerns about safety and standards related to medication prescribing, administration and management in care homes.

The partnership, led by the National Care Forum (on behalf of the Care Provider Alliance) involved: the Royal College of General Practitioners, the Royal College of Physicians, the Royal College of Psychiatrists, the Royal Pharmaceutical Society, the Royal College of Nursing, the Health Foundation and Age UK.

Source: nationalcareforum.org.uk
Pharmacy Resource: Resource Pack
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Last Checked: 18/11/13 Link Error: Report It

 

Making care safer
Improving medication safety for people in care homes: thoughts and experiences from carers and relatives

This report collects together the testimony given by family and carers of people living in a care home, specifically around issues of medication safety.

Source: health.org.uk
Pharmacy Resource: Report
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Last Checked: 17/08/15 Link Error: Report It

 

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