A project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward

"A systematic approach to ward rounds with a ward round checklist offers a rigorous method to reduce the prevalence of PIMs, and the frequency of adverse drug events. This has important implications in the wider context of growing pressures to deliver higher standards of cost effective clinical care."

Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward
T H Aung, A J Beck, T Siese, R Berrisford
BMJ Quality Improvement Reports 2015;5: doi:10.1136/bmjquality.u207857.w4260

Read more here.

Medication safety curriculum: enhancing skills and changing behaviors

"Students that participate in medication reconciliation/ optimization curricular activities are better prepared to critically assess medications for safety and efficacy in medical practice."

Medication safety curriculum: enhancing skills and changing behaviors
KD Karpa, LL Hom, P Huffman, EB Lehman, VM Chinchilli, P Haidet, SL Leong
BMC Medical Education (2015) 15:234

Read more here.

Pediatric Trigger Toolkits

"Adapted from proven adult trigger tools, the Pediatric ADE Trigger Tool provides a powerful yet simple method to detect medication-related harm in pediatric inpatients. The related Trigger Toolkit available below can help hospitals implement medication system changes to ensure fewer drug-related injuries."

Pediatric Trigger Toolkit: Measuring Adverse Events in the PICU Using a PICU Trigger Tool 
​Child Health Corporation of America

Access the toolkit here.

NICE Guideline: Depression in children and young people

The NICE guideline for depression in children and young people has been updated, with a number of changes to the recommendations for safe and effective antidepressant use.

Depression in children and young people: Identification and management in primary, community and secondary care
NICE guidelines [CG28]
March 2015

Find out more here.

Medication Reconciliation Improvement Through the Use of Video

"During implementation of this project, it became immediately clear that despite the known safety benefits to proper medication reconciliation, these benefits were under appreciated by our front line providers."

Medication Reconciliation Improvement Through the Use of Video
M Dewan, B Kraus, D Davis, J McCloskey
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u207581.w3035

Read more here.

Improving Medication Administration Safety

"Ultimately, these findings affirm that nurse adherence to safe practices reduces medication administration (MA) errors. Although MA errors account for a minority of overall adverse drug events, they are typically not intercepted by other members of the healthcare team. Integrating these findings into evidence-based staffing considerations, nursing education and clinical practice competency validation has the potential to improve the quality, cost, and outcomes of MA."

Improving Medication Administration Safety: Using Naïve Observation to Assess Practice and Guide Improvements in Process and Outcomes
N Donaldson, C Aydin, M Fridman, M Fole
Journal for Healthcare Quality, 2014, 36: 58–68. doi: 10.1111/jhq.12090

Read more here.

Improving the accuracy and turn-around time of controlled drug prescribing for patients being discharged home for end-of-life care

"Re-audit after a pilot period showed a significant improvement in both error rate and dispensing time of these medications. This then allowed for better use of staff time within the pharmacy department, and a smoother and safer discharge for our patients going home for end of life care."

Improving the accuracy and turn-around time of controlled drug prescribing for patients being discharged home for end-of-life care

S Daniel, J Patel, D Benson
BMJ Quality Improvement Reports 2014;3: doi:10.1136/bmjquality.u203589.w1595

Read more here.

Medicines optimisation prototype dashboard

“Medicines Optimisation Prototype Dashboard” brings together a range of medicines-related data in a way never previously done. We hope it will help CCGs explore how well their local populations are supported to optimise medicines use. The dashboard is presented to allow local NHS organisations to develop improvements"

Medicines optimisation - CCG prototype dashboard

NHS England

Read more here. 

Review of specialist pharmacy services in England

"This report summarises the findings and recommendations of the Review of Specialist Pharmacy Services (SP Srvcs) in England."

The Review of Specialist Pharmacy Services in England

K Ridge

NHS England

May 2014

Read more here. 

Professional standards for homecare services in England

"The Royal Pharmaceutical Society Professional Standards for Homecare Services in England aims to ensure that patients experience a consistent quality of homecare services that will protect them from incidences of avoidable harm and help them to get the best outcomes from their medicines"

Handbook for homecare services in England: professional standards
Royal Pharmaceutical Society
May 2014

Read more here.

New medicines, better medicines, better use of medicines

"The Guide ... highlights the major challenges and opportunities faced when creating new medicines, improving existing medicines or ensuring the better, safer use of medicines, and makes recommendations and calls for action."

New medicines, better medicines, better use of medicines: a guide to the science underpinning pharmaceutical practice 
Royal Pharmaceutical Society
May 2014

Read more here.

Are interventions to reduce interruptions and errors during medication administration effective?

"There is weak evidence of the effectiveness of interventions to significantly reduce interruption rates and very limited evidence of their effectiveness to reduce medication administration errors. Policy makers should proceed with great caution in implementing such interventions until controlled trials confirm their value." 

Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review
MZ Raban, JI Westbrook
BMJ Quality and Safety, 2014; 23: 414-421

Read more here.

International prevalence of adverse drug events in hospitals

"Adverse drug events (ADEs) are frequent in hospitals, occurring either in patients before admission or as a nosocomial event, and either as a drug reaction or as a consequence of a medication error. Routine data primarily recorded for reimbursement purposes are increasingly being used on a national level both in pharmacoepidemiological studies and in trigger tools. The aim of this study was to compare the prevalence rates of coded ADEs in hospitals on a transnational level."

International prevalence of adverse drug events in hospitals: an analysis of routine data from England, Germany, and the USA
J Stausberg
BMC Health Services Research, 2014, 14:125

Read more here.

Patient safety alerts to increase incident reporting

NHS England and the Medicines and Healthcare products Regulatory Agency have issued two patient safety alerts to improve incident reporting for medication errors and medical devices. They aim to improve data report quality and prompt the establishment of national networks of online learning which will work to improve communication and sharing of safe practice ideas in order to reduce harm.

Find out more and access the alerts with their supporting information here.

Event: Free webinar: How to write about quality and safety and get published

The Health Foundation provides a series of Improvement Science Webinars. On 22nd November, at 4pm (UK time), there will be a free Webinar called "the leading improvement science researcher and well-published author Mary Dixon-Woods, Professor of Medical Sociology , University of Leicester, will be exploring how to write-up your research/improvement project for publication.

Find out more here.

Increasing reporting rates and reducing harm

"Actively developing a transparent and positive safety culture at the unit level can improve medication safety."

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit
KM Abstoss, BE Shaw, TA Owens, JL Juno, EL Commiskey, MF Niedner
BMJ Quality and Safety, 2011, 20(11):914-922

Read more here.