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Pharmaceutical Services Negotiating Committee

NPSA Alerts

NPSA survey on anticoagulation (March 2010)

The National Patient Safety Agency (NPSA) is keen to understand how patient safety alert 18 ‘Actions that can make anticoagulation safer' can be further supported. The NPSA has commissioned King's College to undertake research on this.

The research team at King's College, London want pharmacists (who work in England) to engage with this research because this will ensure that service developments will be informed by those who deliver services directly to patients.

Responses and participation will remain totally confidential and the questionnaire does not require your name or any other information that would disclose your identity. If you would like any more information about this survey please contact karen.rosenbloom@kcl.ac.uk.

Please click the link below to take you to the survey. The survey should take no longer than 5-10 minutes to complete.

To access the online survey click here.

NPSA report: vaccine cold storage (January 2010)

A National Patient Safety Agency (NPSA) Rapid Response Report on vaccine cold storage was issued on 21st January.

"Between January 2005 and April 2009, about 50 million doses of childhood vaccines were distributed in the UK. During this period the National Patient Safety Agency (NPSA) received 260 reports of incidents from a range of NHS organisations related to vaccination cold storage. Themes identified from these reports include: delay in storage of vaccines (especially after delivery); storage at wrong temperature; fridge switched off or broken; power cut or fridge door left open; no temperature monitoring; inadequate or missing equipment; and inappropriate use of domestic fridges. It is unknown if any of these incidents led to significant harm.

"In addition, evidence provided to the NPSA from an audit of 96 practices in one English area showed significant problems of vaccine storage and remedial action by the primary care organisations included recall of over 500 patients for repeat vaccination. These local findings, together with incidents reported to the NPSA, suggest scope for improvement in vaccine storage.

"Advice does exist on this issue, although our evidence suggests that this is not always followed. The NPSA have therefore issued a Rapid Response Report to address some of theses issues including raising staff awareness on under-recognised risks (such as vaccines freezing) and reinforcing existing guidance to check and action on results. Rationale for theses actions and a suggested compliance checklist for implementation are included in the supporting information."

Further details of this guidance and supporting information are available on the NPSA website.

Queries can be directed to rrr@npsa.nhs.uk or 0207 927 9890

NPSA Patient Safety Alert - safer Lithium therapy (March 2009)

The National Patient Safety Agency (NPSA) has issued a patient safety alert on safer Lithium therapy in response to reports of harm caused to patients, including fatalities, involving Lithium therapy. A recent audit has also demonstrated less than optimal monitoring of lithium and a failure to adequately prepare patients to recognise therapy-induced side effects or toxicity.

The alert is required to be implemented by 31st December 2010  by all healthcare organisations in the NHS where lithium therapy is initiated, prescribed, dispensed and monitored. By this deadline, the following should be in place:

• Patients prescribed lithium are monitored in accordance with NICE guidance;

• There are reliable systems to ensure blood test results are communicated between laboratories and prescribers;

• At the start of lithium therapy and throughout their treatment patients receive appropriate ongoing verbal and written information and a record book to track lithium blood levels and relevant clinical tests;

• Prescribers and pharmacists check that blood tests are monitored regularly and that it is safe to issue a repeat prescription and/or dispense the prescribed lithium;

• Systems are in place to identify and deal with medicines that might adversely interact with lithium therapy.

The NPSA has developed a patient information booklet, lithium alert card and record book for tracking blood tests. These resources should be made available to all patients on lithium therapy and their use supported by healthcare professionals. Details of how to obtain these materials are included in the supporting information document accompanying the alert, which provides additional understanding for implementation and supports arguments for NHS service engagement.  It contains further details of the actions recommended, the background to the alert (lithium therapeutics and monitoring, prescribing, and triggers for action) and a compliance checklist.

The NPA is producing a standard operating procedure (SOP): Supplying Lithium therapy, accompanied by guidance notes.

The NPSA Patient Safety Alert can be accessed by clicking here.  

NPSA Clarification statement on the use of the NHS number as the national identifier.(Sept 2009)

The NPSA has issued clarification following its Safer Practice Notice on the risk to patient safety of not using the NHS Number as the national identifier for all patients.    

PSNC raised the issue of community pharmacy’s ability to comply with this Safer Practice Notice when it was first issued. Our concerns were accepted, along with those of other healthcare organisations, and a holding statement was agreed with NPSA which was published in CPN and on the PSNC website. 

Official confirmation of the deferral for community pharmacy to comply with the recommendations relating to the use of the NHS number as the national identifier by this month’s deadline has been issued today by NPSA and is now available on their website.

The information has also been circulated via the CAS system, and the main message is:

The NPSA, NHS CFH and IHC accept that the healthcare organisations concerned cannot, at present, comply with all the SPN recommendations. Healthcare organisations can, however, comply with some of the recommendations and should prepare for the time when they can access and search for NHS Numbers. This should include:

1. Where the NHS Number is available, using it in correspondence with the patient.

2. Where the healthcare organisation has received correspondence without an NHS Number from a healthcare organisation that can access or search for the NHS Number, requesting the NHS Number from the sending organisation.

3. Assisting patients to know more about their NHS Number, which can include displaying the NHS CFH leaflet about the NHS Number which is available on the NHS CFH website.  

Reducing risk of overdose with Midazolam injection in adults (June 2009)


In response to reports of 498 dose-related patient safety incidents relating to the either the incorrect dose of Midazolam injection being prescribed or administered the National Patient Safety Agency (NPSA) has issued a rapid response report.

To view the alert in full click on the following link:

http://www.nrls.npsa.nhs.uk/resources/?entryid45=59896

NPSA Clarification statement on the use of the NHS number as the national identifier.(Sept 2009)

The NPSA has issued clarification following its Safer Practice Notice on the risk to patient safety of not using the NHS Number as the national identifier for all patients.    

PSNC raised the issue of community pharmacy’s ability to comply with this Safer Practice Notice when it was first issued. Our concerns were accepted, along with those of other healthcare organisations, and a holding statement was agreed with NPSA which was published in CPN and on the PSNC website. 

Official confirmation of the deferral for community pharmacy to comply with the recommendations relating to the use of the NHS number as the national identifier by this month’s deadline has been issued today by NPSA and is now available on their website.

The information has also been circulated via the CAS system, and the main message is:

The NPSA, NHS CFH and IHC accept that the healthcare organisations concerned cannot, at present, comply with all the SPN recommendations. Healthcare organisations can, however, comply with some of the recommendations and should prepare for the time when they can access and search for NHS Numbers. This should include:

1. Where the NHS Number is available, using it in correspondence with the patient.

2. Where the healthcare organisation has received correspondence without an NHS Number from a healthcare organisation that can access or search for the NHS Number, requesting the NHS Number from the sending organisation.

3. Assisting patients to know more about their NHS Number, which can include displaying the NHS CFH leaflet about the NHS Number which is available on the NHS CFH website

Reducing Dosing Errors with Opioid Medicinesblister pack tablets (Jan 2009)

In response to reports of five deaths and over 4,200 dose-related patient safety incidents concerning opioid medicines up to June 2008, the National Patient Safety Agency (NPSA) has issued a rapid response report designed to help reduce potential harm to patients taking this type of medication.

This guidance applies when the following opioid medicines are prescribed dispensed or administered: Buprenorphine, diamorphine, dipipanone, fentanyl, hydromorphone, meptazinol, methadone, morphine, oxycodone, papaveretum and pethidine.

The alert is for immediate action by the NHS and the independent sector.

The alert should be read in detail, but the key messages for community pharmacists are that when opioid medicines are prescribed, dispensed or administered, in anything other than acute emergencies, the pharmacist should:

  • Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient. This may be done for example through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records.
  • Ensure where a dose increase is intended, that the calculated dose is safe for the patient (e.g. for oral morphine or oxycodone in adult patients, not normally more than 50% higher than the previous dose).
  • Ensure they are familiar with the following characteristics of that medicine and formulation: usual starting dose,frequency of administration, standard dosing increments, symptoms of overdose, common side effects.

Healthcare organisations should ensure local medicines and prescribing policies, including Standard Operating Procedures, are reviewed to reflect this guidance.

Dr Bruce Warner, Senior Pharmacist at the NPSA, said: "As the use of opioids across the NHS increases it is vital that we ensure safe doses are administered. Opioids are very strong pain killers and the wrong dose could be fatal. Every member of the healthcare team has responsibility to check that the intended dose is safe for the individual patient.  Knowledge of previous opioid dose is essential.  This Rapid Response Report will help raise awareness of some common errors that have occurred across NHS settings in recent years with an aim of ensuring safer use in the future."

To view the alert in full click on the following link: http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/rapidrr/reducing-dosing-errors-with-opioid-medicines/

PSNC will be evaluating the impact of the NPSA alert on workload in pharmacies with a view to making a claim for compensatory funding under the ‘regulatory burden' component of the pharmacy contract's annual funding uplift formula.


Anti-Cancer Medicines (July 2008)

The National Patient Safety Agency (NPSA) has issued a safety alert concerning oral anti-cancer medicines following a large number of safety incidents. Half of reported incidents related to the wrong dosage, frequency, quantity or duration or oral anti-cancer medicines.

These medicines are increasingly being used in hospitals and in the community which has highlighted the increased risks involved if non-specialist practitioners prescribe, dispense or administer these oral medicines. Unlike with anti-cancer injectables there are currently no safeguards in place for oral anti-cancer medicines in primary care.

The NPSA have stated that pharmacists and their staff must be made aware that the prescribing, dispensing and administering of oral anti-cancer medicines should be carried out and monitored to the same standard as injected therapy. This requires that: 

  • Staff dispensing oral anti-cancer medicines should be able to confirm the prescribed dose is appropriate for the patient, and that the patient is aware of the required monitoring arrangements, by having access to information in the written protocol and treatment plan from the hospital where treatment is initiated and advice from a pharmacist with experience in cancer treatment in that hospital.
  • Patients should be fully informed and receive verbal and up-to-date written information about their oral anticancer therapy from the initiating hospital. This information should include contact details for specialist advice, which can be shared with non-specialist practitioners. Written information, including details of the intended oral anti-cancer regimen, treatment plan and arrangements for monitoring, taken from the original protocol should be given to the patient. When shared with pharmacists and dispensing staff, this would enable the above dispensing requirements to be satisfied.
  • Full use should also be made of NHS cancer centre web sites to provide information for healthcare staff, patients and carers to ensure the safe use of oral anti-cancer medicines.The NPSA use the term oral anti-cancer medicines to describe those medicines with direct anti-tumour activity, including: bexarotene, busulfan, capecitabine, chlorambucil, cyclophosphamide, estramustine, etoposide, fludarabine, hydroxycarbamide, idarubicin, lomustine, melphalan, mercaptopurine, methotrexate, mitotane, procarbazine, tegafur/uracil, temozolomide, tioguanine, treosulfan and vinorelbine. In addition targeted therapies such as the kinase inhibitors dasatinib, erlotinib, imatinib, sorafenib, and sunitinib are also included. The NPSA use of this term does not include hormonal or anti-hormonal therapy used to treat cancer.

Where the use of these medicines (such as Methotrexate) is for non-cancer treatment, a risk assessment should be undertaken and the guidance applied as appropriate.

The NPSA alert demands immediate action by the NHS and the independent sector. The deadline for implementation of these changes is 22nd July 2008.

More Information
Safety Alert in Full (NPSA Website)

Related Links
NHS Cancer Programme Website

List of NHS Cancer Networks


Fire Hazard with Paraffin Based Skin Products on Dressings and Clothing (Nov 2007)

The National Patient Safety Agency (NPSA) is alerting all healthcare staff involved in the prescribing, dispensing or administration of paraffin based skin products of a potential fire risk. Following a patient safety incident, the NPSA commissioned the Health and Safety Executive to undertake fire hazard testing with White Soft Paraffin at concentrations of over 50% on a variety of bandages, dressings and clothing. The results showed the ability to reproduce the fire hazard in a controlled environment.

The following commonly prescribed products contain White Soft Paraffin at concentrations of over 50%:

                                       Product    

Concentration of WSP
Diprobase Ointment 95%
Emmolin Emollient Aerosol Spray 50%
Emulsifying Ointment 50%
Liquid Paraffin 50%/White Soft Paraffin 50% Ointment 50%
White Soft Paraffin 100%
Zinc And Salicylic Acid Paste BP 50%
Zinc Ointment BP 72.25%


The evidence currently only relates to White Soft Paraffin and there is currently no evidence of a risk of fire hazard with preparations containing concentrations of WSP lower than 50%. As a precaution, pharmacists may wish to also provide information to patients using products that contain high concentrations of other paraffin products, for example Yellow Soft Paraffin and Liquid Paraffin.

Commonly prescribed products which may be applied directly to the skin and which contain high concentrations of other paraffin products are set out in the table below:

                       Product

                     Contains:
Dithranol Ointment YSP
Epaderm Emulsifying Wax, LP & YSP
Hydromol Ointment Emulsifying Wax, LP & YSP
Imuderm Liquid LP
Infaderm Therapeutic Oil LP
Yellow Soft Paraffin BP YSP
Zinc & Coal Tar Paste BP Emulsifying Wax & YSP

NB: This list is not exhaustive
LP = Liquid Paraffin; YSP = Yellow Soft Paraffin

Paraffin products can also be found as constituents in some commonly prescribed ‘specials’ creams and ointment, for example white soft paraffin can be used as a diluent to lower the strength of a ready prepared ointment.

More Information

NPSA Website: Alert in full and Guidance Materials
 

 

Anticoagulant therapy information for community pharmacists (March 2007)

In March 2007 in response to a series of reports of patient safety incidents involving anticoagulants received from all sectors of the NHS in England and Wales, the National Patient Safety Agency (NPSA) issued guidance designed to help reduce potential harm to patients taking this type of medication.

The alert should be read in detail, but the key messages for community pharmacists are that they should:

  • Ensure that patients on anticoagulant therapy have received appropriate verbal and written information at the start of their therapy, and when necessary throughout their treatment. In practice, this means making sure that patients have received a ‘yellow book’ and ensuring that they (or their carers) fully understand its contents.
  • Ensure that before dispensing a repeat prescription for anticoagulant medication, they check that the patient’s INR is being monitored regularly and that it is at a safe level for the repeat prescription to be dispensed. One way of doing this is to ask to see the patient-held INR record,which may be in the form of a single printed sheet, a small booklet or another format used locally.
  • Check if one or more  clinically significant interacting medicines for patients already on oral anticoagulants are dispensed, then arrangements for additional INR blood tests have been made and that the anticoagulant service has been informed that an interacting medicine has been prescribed.
  • Ensure that doses are expressed in mg and not in number of tablets.
  • Ensure that a risk assessment is undertaken on the use of monitored dosage systems for anticoagulants for individual patients. The general use of monitored dosage systems for anticoagulants should be minimised.

  More information

NPSA Website: Alert in full and Guidance Materials

The National Patient Safety Agency (NPSA) is keen to understand how patient safety alert 18 ‘Actions that can make anticoagulation safer' can be further supported.
In March 2010 the NPSA commissioned King's College to undertake research on this. To take part in this online survey  click here

PSNC will be evaluating the impact of  NPSA alerts on workload in pharmacies with a view to making a claim for compensatory funding under the ‘regulatory burden’ component of the pharmacy contract’s annual funding uplift formula.