From 2022, the IMSN publish a bi-annual Medication Safety Bulletin highlighting items of interest regarding safe medication use in hospitals to Irish healthcare professionals. These bulletins can be found below:
Serious allergic and anaphylactic reactions can occur when knowndrugallergens are prescribed, dispensed and administered to patients. This harm is preventable. Rapid recognition and treatment of drugallergy is essential.
Serious allergic and anaphylactic reactions can occur when known drug allergens are prescribed, dispensed and administered to patients in hospitals and the community. This harm is preventable. This document outlines how risks can be reduced.
Whilst resources to support frontline staff in the stepwise implementation of medicationsafety programmes are available in other jurisdictions, few publications have addressed this issue in an Irish healthcare context. It was with the intention of addressing this gap that the IMSN compiled the following document in 2018 which outlines the building blocks for the design of a medicationsafety programme based on the first-hand experience accrued by MedicationSafety Officers in hospitals in Ireland over the past several years. Our hope is that healthcare staff will use this guide to support them in the practical implementation of the HIQA medicationsafety recommendations and in establishing best practice in their respective organisations. This document has been reviewed and updated in line with best practice in 2023, and is currently on it’s second version.
Materials developed by NHS Specialist Pharmacy Services and adapted by HSE & Irish Medication Safety Network with permission from NHS SPS.
This guidance is to alert healthcare staff in hospitals to
undertake additional checks of medication labelling and packaging due to the
increased use of products staff may be unfamiliar with.
The concentration or volume of medication in each pack may differ from products usually used. There may also include unfamiliar brand names in use therefore the importance of checking the approved generic name is emphasized.
Sound-alike look-alike drug (SALAD) errors have occurred in maternity care with serious or extreme consequences. If a prostaglandin analogue e.g. misoprostol or dinoprostone, is used in error during pregnancy, serious patient harm including preterm delivery and foetal/neonatal death may occur.
Apixaban (Eliquis), dabigatran (Pradaxa), Edoxaban (Lixiana) and rivaroxaban (Xarelto) are anticoagulants licensed in varying doses in adults for prevention and treatment of venous thromboembolism and for non-valvular atrial fibrillation.
These agents were previously known as NOACs (Novel Oral Anticoagulants)
The IMSN advocates for an integrated system that ensures that medicines information flows without restriction or distortion throughout the health system. Electronic transmission of prescriptions, enabled in 2020 by COVID-related legislative changes, is a step forward for medication safety, provided that potential risks are addressed. This document outlines the IMSN position on implementation of electronic transmission of prescriptions in the secondary care setting and related medication safety considerations. It will consider the common barriers and facilitators to implementation of this change in practice, with reference to similar systems in place in other countries.
Rhabdomyolysis is a rare complication of statin monotherapy. However the risk of rhabdomyolysis is much higher when patients are exposed to the combination of systemic fusidic acid (as fusidic acid hemihydrate/sodium fusidate; hereafter referred to simply as ‘fusidic acid’) and a statin, compared with exposure to a statin alone.
In an unprecedented move to address one of healthcare’s most pressing challenges, Dublin Castle will play host to the first-ever All-Island Medication Safety Conference on 28–29 November 2024. This historic event aims to bridge healthcare practices across borders, uniting experts, researchers, policymakers, and patient advocates to bolster medication safety in both the Republic and Northern Ireland.
A Timely Focus on Patient Safety
With adverse drug reactions contributing to nearly 10% of emergency admissions among patients over 65 in Ireland, the need for targeted action has never been clearer. The Irish Medication Safety Network (IMSN) and Transforming Medication Safety in Northern Ireland (TMSNI) will lead this conference, supported by collaborators including the Departments of Health from both jurisdictions, the Health Service Executive (HSE), Royal College of Surgeons in Ireland (RCSI) and a network of patient advocates including Patients for Patient Safety Ireland and Parkinson’s Ireland.
Niamh O’Hanlon, Chair of IMSN, said: “This conference represents a pledge to build a safer healthcare future across Ireland. We need to share successes, confront challenges and leave with strategies that resonate from Belfast to Cork.”
Day 1: Pathways to Change On Thursday, 28th November, the focus will be on Pathways to Achieving Medication Without Harm, an interactive workshop where healthcare professionals, researchers, patients, and advocates will discuss what’s working well and how those successes can be scaled island-wide. Attendees will hear research updates, impactful patient stories and engage in discussions led by experts such as Ciara Kirke, Clinical Lead of the HSE’s National Medication Safety Programme, Dr Caitríona Cahir, RCSI School of Population Health and Anne Mooney from Patients for Patient Safety.
Dr Caitríona Cahir said: “Adverse drug reactions are a particular issue for older people and in our work at RCSI, we are trying to better understand the connection between high-risk prescribing and poor health outcomes. The cross-disciplinary conversations about medication safety that will take place at this conference will advance our collective efforts to reduce the risk and improve patient outcomes.”
Day 2: All-Island Medication Safety Conference Friday’s plenary will open with keynote remarks from Kate O’Flaherty, Director of the National Patient Safety Office and Prof Cathy Harrison, Chief Pharmaceutical Officer for Northern Ireland.
Kate O’Flaherty said “Medication safety is a global patient safety challenge which requires everyone from patients to researchers, clinicians to policy-makers, to play their part. We in Dublin are delighted to host this first all-island conference which symbolises our collective will to meet this important challenge”.
Prof Cathy Harrison adds, “Collaboration is key. By sharing knowledge, we amplify our impact and reinforce the culture of safety in every hospital and clinic on this island.”
Insulinis a high risk drug which has the potential to cause serious harm if it is not used correctly.1 Until recently, allinsulinavailable on the European market contained 100 units / mL. A high-strengthinsulinis one which containsinsulinat a concentration of more than the standard 100 units / mL.2 These high-strengthinsulinproducts may contain, for example, 200 units / mL or 300 units / mL. There is a potential for harm if these products are not prescribed, dispensed, and administered properly.
The US Institute for Safe Medication Practices considers insulin to be one of the top 5 ‘high-alert’ medications i.e. drugs that bear a heightened risk of causing significant patient harm when they are used in error.
Lithium is indicated for the prophylaxis and treatment of mania, in the prophylaxis of bipolar disorder and as an augmentation strategy for patients with treatment-resistant depression.
Saint John of God Hospital Pharmacy and the HSE National Medication Safety Programme collaborated to launch a national patient information booklet on lithium therapy. It is intended to promote and support safer lithium therapy, and empower patients to engage with their Healthcare Professional to discuss all aspects of lithium therapy, monitoring, and side-effects.
This booklet has been produced by Audrey Purcell, Chief 2 Pharmacist, Saint John of God Hospital, and supported by Professor Dolores Keating, Chief 1 Pharmacist, and the Hospital Drug and Therapeutics Committee. It has been reviewed and endorsed by Ciara Kirke, HSE Clinical Lead, National Medication Safety Programme, and the national print supported by the HSE’s National Quality and Patient Safety Directorate.
It has been edited and reviewed by the National Adult Literacy Agency and has successfully been awarded the plain English mark by NALA.
It has been reviewed by the Irish Medication Safety Network, Irish Pharmacy Union, the College of Psychiatrists, and the Irish College of GPs.
The booklet contains an information section with important safety and clinical information on Lithium therapy, and a record book to record essential information on lithium levels and blood test results.
Lithium booklets will be distributed from the HSE directly to Hospital Pharmacies, and to Community Pharmacies via the IPU Review. GPs may sign-post patients to Community Pharmacists to avail of a booklet.
Lithium booklets may be re-ordered from Saint John of God Hospital Pharmacy: hospital.pharmacy@sjog.ie
Magnesium sulphate is indicated in the management of pre-eclampsia and also for fetal neuroprotection if there is a risk of preterm delivery. Intravenous magnesium has been repeatedly associated with medication errors internationally and locally. One US report described 52 cases of accidental IV magnesium overdose. IV magnesium errors may result in serious patient harm or death. Such errors are well understood and effective preventative strategies are available.
The Irish Medication Safety Network (IMSN) convened a working group to develop medication incident reporting guidelines. The IMSN guidelines were drafted using the framework developed by the WHO and by building on the systems already in place in Irish hospitals. These guidelines include guidance for completing a Medication Incident Report and descriptions of incident categories, a sample Medication Incident Report (MIR) template, and general recommendations to assist a hospital that intends to update its current MIR form or to implement a new MIR form.
In May 2014 we published updated and revised versions of these documents which can be found at these links:
The Irish Medication Safety Network (IMSN) convened a working group to develop medicationincidentreporting guidelines. The IMSN guidelines were drafted using the framework developed by the WHO and by building on the systems already in place in Irish hospitals. These guidelines include guidance for completing a MedicationIncident Report and descriptions of incident categories, a sample MedicationIncident Report (MIR) template, and general recommendations to assist a hospital that intends to update its current MIR form or to implement a new MIR form.
In May 2014 we published updated and revised versions of these documents which can be found at these links:
Methotrexate is a high-risk drug, i.e. serious patient harm can occur as a result of errors involving incorrect frequency (daily rather once weekly), incorrect strength tablets, incorrect strength tablets, or from an adverse drug reaction. Care must be taken with methotrexate use at all stages of medication use, including at transitions of care. Click here to view IMSN’s Safety Alert on the Use of Once Weekly Oral Methotrexate
Medicines management is crucial in the care of the patient with Parkinson’s Disease (PD) when they are admitted to hospital, either electively or in an emergency.
Missed or delayed doses can impair patients’ swallow, increase their risk of aspiration, render them immobile and prone to falls and fractures, and at worst, progress to Neuroleptic Malignant Syndrome, which can lead to coma or death.
In hospitalised patients, administration of contraindicated medications has been shown to increase length of hospital stay and mortality. Patients are also more susceptible to hallucinations, mental status changes and nausea, symptoms that are typically treated with anti-dopaminergic medications.
Potassium chloride (KCl) is a high-risk medication. The WHO/Joint Commission recommends that health-care organisations have systems and processes in place for the promotion of safe practices with potassium chloride and other concentrated electrolyte solutions. For hospitals that do not currently have a potassium policy in place, this document can form the basis of such a policy. The guideline below replaces the previous version published by the IMSN in 2013
Permanent skin staining can occur with use of parenteral iron if there is extravasation (leakage of fluid) into the surrounding tissues. An increase in reports of iron staining in recent years has been attributed to increased use of intravenous (IV) iron. While skin staining can also occur with intramuscular or IV iron , this safety alert focuses on IV administration.
The International Medication Safety Network have published their recommendations for the Global Implementation of Safe Oxytocin Use Practices 2023. The Irish Medication Safety Network contributed to the document and endorse the recommendations.
A number of tools are available to encourage and empower both patients and their caregivers and health care professionals (for example nurses, physicians, pharmacists) to take an active role in ensuring safermedicationpractices and medication use processes including prescription, preparation, dispensing, administration and monitoring.
“5 questions to ask” tool (adopted from ISMP Canada) is available here
The World Health Organisation also has useful resources available at the following links:
“it deosn’t mttaer in waht oredr the ltteers in a wrod are the olny iprmoatnt tihng is taht the frist and lsat ltteer are in the rghit pcale” Surprisingly, many people can. This may explain why the following similar-sounding drugname pairs were frequently involved in errors / near misses in a recent survey of Irish hospitals.
The term SALADs
(Sound-Alike Look-Alike Drugs) refers to look-alike and sound-alike drug
names and look-alike product packaging which can cause confusion resulting in
potentially harmful medication errors. The IMSN’s SALAD Bar is a comprehensive
list of SALAD pairs which have been confused or have potential for confusion.
It is to be read alongside the updated briefing document on SALADs in the
hospital setting, which outlines the factors contributing to SALAD errors, and
various strategies and actions that can be taken to reduce the risk.
The list will be
updated periodically. If you have any SALAD pairs from your institution which
you think are relevant to the Irish setting, please e-mail enquiries@imsn.ie with “SALAD
BAR” in the Subject line with details (and photographs for LOOK-ALIKE
pairs) for consideration. SALAD concerns should also be reported to the
manufacturers and appropriate agencies.
I am very pleased to be here with you today to recognise the work being done by your organisation and its importance to pharmaceutical healthcare in Ireland. As hospital-based pharmacists, you play a vital role on a daily basis in leading the team that ensures the right medication gets to the right patient at the right time.
As members of the Irish Medication Safety Network you take a wider view and pool your collective learning to ensure safety across the sector. Not only that, you look to developments in pharmaceuticals and pharmaceutical safety internationally and ensure that Ireland is well positioned to serve its healthcare staff and patients.
It’s very fitting that this conference is being held in Cork for what I understand is the first time. Cork is home to 8 of the top 10 pharmaceutical companies in the world and has a decades long history of producing some of the most widely used medication in the world. These medications are manufactured to a very high standard in what is a highly regulated environment. As Minister for Enterprise, Trade and Employment, and as a Corkman I am very proud of the quality of the work done in our city to produce such life enhancing medication.
But it is of course essential that the medication is used in the best way possible to benefit patients. The safety and regulation continues right up to the point when the patient receives the medication and beyond. I know there is a broad team of healthcare professionals who ensure that this happens and as hospital based pharmacists you play a particularly key role. Your training, your experience and your expertise are all essential to patient care. But it is the power of your collective knowledge, and your willingness to share that knowledge which is what makes your organisation so effective. The Irish Medication Safety Network has developed numerous national guidelines on the management of high-risk medications and medication practices. I know you also publish medication safety alerts and briefings.
These are essential services to the healthcare community and you do this as an independent, voluntary organisation – a network of committed professionals getting together to advance your discipline, promote best practice, serve the wider healthcare community.
Promoting the optimal use of medicines within our health systems is an essential aspect of your work. The IMSN is devoted to promoting patient safety and highlights the importance of medication safety for its impact on patient health. But its impact as a cost to the healthcare system cannot be overstated. Globally, the cost associated with medication errors has been estimated at $42 billion USD annually. This is funding that could be put to more beneficial use.
Medication Errors can occur at all stages of the medication use process and the work of this organisation is crucial to raising awareness of such errors and enabling us to learn from, and prevent, such errors occurring in the future.
In 2017, the third World Health Organisation (WHO) Global Patient Safety Challenge report, ‘Medication Without Harm’ was launched. The aim of this report is to reduce severe avoidable medication-related harm by 50% globally and your organisation is striving to implement and deliver upon this aim.
For all of these reasons, I am delighted to welcome you and your conference to Cork today. UCC is the obvious choice of location with its College of Medicine and Health offering health professional degrees in over 10 healthcare disciplines.
Medication Safety has been at the forefront of Research here in UCC for many decades, but its prominence has been substantially raised since the foundation of the School of Pharmacy here in UCC, 20 years ago. Since then, researchers at the School of Pharmacy in UCC have published over 150 peer reviewed papers specifically focused on medication optimisation and patient safety.
The School of Pharmacy has played a significant role in the education and training of Pharmacists, key members of the multidisciplinary team and arguably medication specialists, for our healthcare sector. This has been achieved through their world class master’s in pharmacy, master’s in clinical pharmacy and PhDs in Clinical Pharmacy research.
This year’s conference Smarter Technology for a Safer tomorrow is an opportunity for delegates to share, learn and celebrate best practice in medication safety and enhance patient safety across the healthcare sector in Irish hospitals, public and private.
I know that there will be extensive discussion between colleagues here today, with wide networking opportunities. I would like to wish you all the very best for a successful conference today and sincere thanks to you all, for the work you do in our hospitals though out the country in promoting and ensuring a safer environment of our patients.
The IMSN have updated their guidance on the safe use of IV paracetamol (version 2, Nov 2019)
While paracetamol has been used orally for many decades, the introduction of an IV formulation brought new risks, some of which were not experienced with oral and rectal products.
The World Health Organisation (WHO) has published guidance in relation to administration of vinca alkaloids via intravenous minibag infusion to avoid accidental death
Our previous guidance document on this subject, produced in 2008 and revised in 2010 has now been withdrawn.
This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Cookie settingsACCEPT
Privacy & Cookies Policy
Privacy Overview
This website uses cookies to improve your experience while you navigate through the website. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. We also use third-party cookies that help us analyze and understand how you use this website. These cookies will be stored in your browser only with your consent. You also have the option to opt-out of these cookies. But opting out of some of these cookies may have an effect on your browsing experience.
Necessary cookies are absolutely essential for the website to function properly. This category only includes cookies that ensures basic functionalities and security features of the website. These cookies do not store any personal information.
Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. It is mandatory to procure user consent prior to running these cookies on your website.
