Black Triangle

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Pharmaceutical related talk about medicines, adverse drug reactions. medication errors and marketing...

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Monday, June 30, 2003

FDA slipping?: From a reader, an interesting story about the FDA: Critics, including members of Congress, former F.D.A. officials, lawyers, doctors and consumer groups, say they see a clear shift in how the agency is performing one of its main functions: policing the marketing of drugs, food and medical devices. The agency has become willing to let some problems slip by, these critics say, and to allow the companies it regulates to go further with their marketing claims.

"The core of the agency's mission has always been protecting the public's health," said William B. Schultz, a lawyer who was the F.D.A.'s deputy commissioner for policy from 1994 to 1998. "Now the agency is thinking about allowing other considerations that would undermine that."
New York Times
posted by Anthony Cox at 9:07 PM | permalink


Vincristine manslaughter case: "If, when you have heard the evidence, your judgement is that his conduct in the events that caused the death of Wayne Jowett fell far below the standard to be expected of a reasonably competent doctor holding his position and that conduct actually caused his death, then the law says that amounts to manslaughter." Bruce Houlder QC in the Wayne Jowett case.

Should this case have even been brought to court? When you read the Toft report, does that make you think it all came down to the actions of one individual? Does the fact that the government has recognised that the system needs making safer mean nothing? What about the Kent Wood report?

An official inquiry into the death of a teenager who died after doctors injected a powerful cancer treatment drug into his spine instead of a vein has concluded that "human error" was not the sole cause of the incident.

The Department of Health (DoH) inquiry report says Wayne Jowett, 18, of Keyworth, near Nottingham, died as a result of a "complex amalgam of human organisational, technical and social interactions" at the hospital where he received the injection.


Getting the Crown Prosecution Service and the Department of Health to pull in the same direction to improve patient safety is going to be hard work.
posted by Anthony Cox at 4:56 PM | permalink

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Sunday, June 29, 2003

Do you want chips with your prescription? : Pharmacogenomics starting to deliver? Yahoo.

The era of personalized medicine came a step closer Wednesday with the launch of the world's first "gene chip" for testing how people will react to drugs. [..]

Some 10 percent of Caucasians and 20 percent of Asian populations are poor metabolites of drugs, while a smaller proportion of people are ultra-fast.

Both groups are at risk if given standard doses, with poor metabolites - whose bodies retain medicines longer than normal - likely to suffer significant adverse reactions and ultra-fast metabolites in danger of not receiving enough drug.

The Roche test looks for variations in genes known as CYP2D6 and CYP2C19.

"There is an increasing awareness of the important role these genes play in metabolizing an estimated 20-25 percent of drugs already on the market," said Greg Heath, head of Roche Molecular Diagnostics Clinical Genomics Business.

posted by Anthony Cox at 1:55 PM | permalink


The law: Don't know your 89/342/EEC from your 92/27/EEC? Read more in this review of UK and European medicinal controls [PDF 85K]
posted by Anthony Cox at 1:26 PM | permalink


Prescribing pharmacists preventing errors? : Yet more data showing drug histories can be vastly improved. This time by the use of pharmacists. [PDF]
posted by Anthony Cox at 1:22 PM | permalink


Methotrexate: A study I was involved with has shown that patients have poor understanding about the risks of treatment with methotrexate, both in terms of adverse effects and interactions. In addition many do not know their dose in terms of milligrams, but only in the number of tablets. So if they get the wrong tablets, they may well take the wrong dose? Time for the 10mg tablets to go? A determination of patient awareness of the safety issues surrounding treatment with methotrexate [PDF]
posted by Anthony Cox at 1:18 PM | permalink

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Friday, June 27, 2003

Advertising Complaints in Oz: Editor of the Australian Prescriber told to withdraw complaint by manufacturer.
posted by Anthony Cox at 9:21 AM | permalink

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Thursday, June 26, 2003

Botox hype starts to wrinkle: "The company that makes anti-wrinkle treatment Botox is misleading patients over the risks of the treatment, say the US authorities.

The Food and Drugs Administration says that advertising on the web and in print does not reveal that more than four in ten people who have the treatment suffer some form of undesired side-effect. "


Botox on the way down, after much hype. The build em' up, knock em' down syndrome does not just apply to celebs, but also their drugs.
posted by Anthony Cox at 5:21 PM | permalink


The Poly Pill: A step forward or something we will all have forgotten about in 3 years?

"Everyone over 55 should take a 'miracle pill' which could cut their risk of having a heart attack or a stroke by 80%, researchers say.

The pill would combine aspirin, a cholesterol lowering drug, three blood pressure lowering drugs and folic acid. "


The editorial on the polypill in the BMJ addresses the issue of adverse effects by saying:

"Will the side effects be so low? Contrary to many perceptions, these drugs have remarkably few side effects. Placebo controlled trials show that when people stop treatment it is rarely for pharmacological reasons. More information from trials on side effects from low dose combinations is clearly needed, especially before contemplating widespread use among people at moderate risk. However, common or serious unanticipated problems seem unlikely since these medications have been studied so extensively and used together so often."

I suppose the real question is does the pooling of trials all with differing inclusion and exclusion criteria give you any idea of the potential adverse effects of a polypill to be adminstered as a preventive treatment to potentially millions? I'm not convinced either way yet about the desirability of the polypill, but I think serious discussions about safety are needed. Although we can be reassured that we know the adverse effects of the agents involved extremely well. You can read the full paper on-line at the BMJ.
posted by Anthony Cox at 5:18 PM | permalink


MHRA under fire: The BBC carries a report on the MHRA today:

The government's medicines watchdog has been attacked by MPs for failing to do enough to protect patients. The Commons public accounts committee said the Medicines Control Agency's efforts to improve patient safety was lacklustre.

It accused the agency of failing to gather information on the side-effects of drugs and not doing enough to inform patients about the risks.

The report follows a similarly damning investigation by the National Audit Office earlier this year.

I'm sorry what did that say? Damning investigation? This would appear to be a gross distortion of the NAO report. OK, things can always be improved but damning? This is from the NAO report executive summary of SAFETY, QUALITY, EFFICACY: REGULATING MEDICINES IN THE UK [PDF]

"The Agency has a good record in ensuring that licensed medicines for sale or supply in the UK have a favourable balance of risks and benefits when used as directed. Twelve licensed medicines have had to be removed from the market in the last five years because of safety concerns, but this compares well with more than 200 new marketing authorisations granted in the UK through national and European procedures during that period, and the four thousand different medicines already on the market. The Agency's licensing decisions also accord well with the views of independent experts in medicines safety in the UK and abroad. Through regulatory action (for example reducing the size of packs of paracetamol tablets to encourage a reduction in the number of tablets sold at one time without prescription) the Agency has, moreover, contributed to improving the safe use of medicines.

The quality of medicines in the UK is also generally high. This is testament to the Agency's rigorous licensing and inspection regime for laboratories, manufacturing plants and wholesale warehouses, which is internationally recognised. The Agency has also achieved some success in prosecuting those selling poor quality or illegal medicines and is currently targeting illegal sales over the internet.

The Agency has taken the lead internationally in developing the science of medicines safety surveillance or pharmacovigilance, which is still evolving. Voluntary reporting by health professionals of suspected adverse drug reactions is a key element of this work and the Agency continues with efforts to encourage better reporting, including extending the scheme to pharmacists, nurses and others."

I've heard of being damned by faint praise, but do the BBC call that faint praise? Did the person who cobbled together that news report even read the NAO report? I'm doubtful.

Update: The Public Accounts Committee Report is on the web. [PDF] With thanks to Paul Baker.
posted by Anthony Cox at 9:26 AM | permalink

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Wednesday, June 25, 2003

Monthly HRT report: Yes, it's that time of the month for another story about HRT. This time.... Breast Cancer.

"Taking HRT can double a woman's risk of developing breast cancer, scientists have warned.

Women over 65 had 1.7 times the risk of developing the cancer if they had taken a combination of oestrogen and progestin for over five years, compared to if they had taken no HRT. "

Some balance of the risks from the expert:

"But women should put it into perspective; one unit of alcohol a day increases a woman's risk of breast cancer by 6%."

He said not having children gave women an extra lifestyle risk of developing the cancer of between 70 and 100%. "

Another paper deals with more data from the Women's Health Initiative trial.
posted by Anthony Cox at 4:20 PM | permalink

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Tuesday, June 24, 2003

Heart errors: The excellent DrugInfoZone (not a blog but sort of like one) has an abstract of a study of medication errors in cardiovascular patients.

"In this report the authors describe the experience of a US-based clinical pharmacist on cardiology wards between September 1995 and February 2000. The 4678 errors detected by that pharmacist during this period were classified according to the type of error, medications involved, personnel involved, stages of drug administration involved, and time of year most frequently associated with errors. This error rate equated to a rate of 24 medication errors per 100 admissions and most commonly involved the wrong drug (36%) or wrong dose (35.3%)"
posted by Anthony Cox at 7:49 PM | permalink


FDA get a move on: The FDA are going to get drugs to market faster. It will be interesting to see the effect of this over the next few years:

"The nation's top drug regulator said on Monday he aims to cut the time it takes to bring new medicines to the public, while still ensuring that any negative side effects are promptly reported to the government.

Speaking at the annual meeting of the Biotechnology Industry Organization in Washington, U.S. Food and Drug Administration commissioner Mark McClellan said the agency will soon announce new initiatives to reduce the cost of drug development by cutting the time the agency spends reviewing applications."

Reuters
posted by Anthony Cox at 7:43 PM | permalink


Burn off those pounds - by dying: The Pharmaceutical Journal has a news item about so-called "fat burning" capsules sold on the internet. I never liked Spam when I was a kid, but I had no idea it could kill people:

Urgent advice has been issued by the Food Standards Agency, to people in the bodybuilding community in particular, about the dangers of consuming products containing 2,4-dinitrophenol (DNP).

The chemical is known to have serious short- and long-term adverse effects on health and has been found in "fat-burner" capsules available via the internet.

The FSA warns: "Taking as few as three or four of these capsules - or 1,000mg of DNP - in one dose could result in death. Smaller amounts (less than one capsule a day) taken over longer periods of time are known to have caused serious human health effects, such as cataracts."

While more and more people become less trustful of government health advice on vaccinations, there seems to be a never-ending line of people willing to believe in the modern day snake-oils sold on the internet.
posted by Anthony Cox at 1:35 PM | permalink


Summer Reading: Hmmm, despite this being one of my favourite books, I can't see this catching on...
posted by Anthony Cox at 10:20 AM | permalink

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Saturday, June 21, 2003

New Server: Up and running. Phew.
posted by Anthony Cox at 12:45 PM | permalink

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Friday, June 20, 2003

The dangers of salt substitution: "It is common practice for physicians to recommend that patients, particularly those with hypertension or heart failure, change to "low salt". However, these are the same patients who are likely to be taking drugs such as ACE-inhibitors which potentiate the risks of dangerous hyperkalaemia. Interestingly, the FDA restricts the amount of potassium in prescribed supplements to 0.099 g; however, these salt substitutes provide 0.53 g in just 1/6 teaspoon! "Low-salt" substitutes are not necessarily safe, and all salt supplementation should be used sparingly or avoided altogether."

The Lancet
posted by Anthony Cox at 8:26 AM | permalink

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Thursday, June 19, 2003

Journalists, Don't Believe the Hype: Guidelines and a cautionary tale for journalists. How to avoid taking in the hype. One example about adverse effects of drug is this:

" Avoid naivete; about side effects. Journalists should learn from the case of pleconaril that a manufacturer is under no obligation to share all information about side effects with journalists before the company's submission to the FDA. But journalists should also be aware that some drug side effects are not discovered until after the drugs are on the market and are used by many people. To report without qualification that a drug has few side effects when it is only in clinical trials is wrong"
posted by Anthony Cox at 11:54 PM | permalink


No more free lunches? 96% of readers of BMJ on-line "would like to see all financial relationships between doctors and drug companies conducted with transparent contracts that are disclosed to patients. "

Seventy-nine percent wanted drug representatives replaced by independent sources of drug information, perhaps a good role for pharmacists (so long as they don't have financial relationships with industry...)
posted by Anthony Cox at 11:46 PM | permalink

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Wednesday, June 18, 2003

Patients have a realistic approach to medical error? A new charter, drawn up by the charity Action for Victims of Medical Accidents (AVMA), is urging the medical profession to keep patients fully informed about risks associated with treatment and to give explanations when things go wrong.

The document says that when avoidable injuries do occur, patients have a "perfectly reasonable right" to explanations, apologies or, where appropriate, financial compensation.

However, the charter stresses that an "error is not in itself an indication of incompetence or negligence" and says doctors should be "applauded" for reporting medical errors honestly.


Health News
posted by Anthony Cox at 9:53 AM | permalink

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Tuesday, June 17, 2003

Light blogging: Please be aware blogging will be light for a few days, as the site is being moved to a new server. Hopefully without too many problems.
posted by Anthony Cox at 1:14 PM | permalink


Objective Industry?: "Sometimes the patient is actually much more informed than the general practitioner that he is talking to. My feeling, from the pharmaceutical industry, is because we are the providers of medicines that people get from the health service, we should not be excluded from [giving information to patients], provided we do it in an objective way."
Trevor Jones, chief executive of the Association of British Pharmaceutical Industries.

You mean like the objectivity they bring to with scientific papers?

"Independent authorship and impartiality are the cornerstones of scientific research. The pharmaceutical giants are using the tools of scientific research as a marketing tool. I believe that these marketing practices are damaging the authority and effectiveness of pharmaceutical research." Susanna T Rees
posted by Anthony Cox at 1:10 PM | permalink

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Thursday, June 12, 2003

Seroxat, what's in a name?: Another article about Seroxat. This time from author Helen Walsh, who tells of her experiences while taking the drug. What struck me was this comment about the how the names of the drugs she was offered influenced her decision on treatment:

"My GP advised that I was suffering from depression and talked me through the whole range of remedial options, from counselling to drugs to homeopathic alternatives. I decided upon prescription drugs. Prozac was mentioned but I opted for Seroxat. It sounded softer, less severe."

More on how drug names are found in this interview with James Dettore:

Where once drugs companies chose chemical and latinate names that blinded the public with science, the turn of the century is witnessing a shift in the direction of airy, abstract names embodying hope and wellness and the promise of transformation. "In most cases, companies are now leaning away from names that are compound-driven and derived," says Dettore. "In the late 1980s, the US tendency was to use names indicative of the product's attributes and benefits, but the UK has always used this more arbitrary, personality- driven strategy. It's an attempt to invoke an essence of the brand."
posted by Anthony Cox at 1:20 PM | permalink


Strategies for Safety: "Developing practical strategies to promote drug and medication safety was the key theme of the 8th congress of the European Association of Hospital Pharmacists held in Florence from 26 to 28 February. "
Read about it at The Hospital Pharmacist.

Some of the thinking that has to be overcome to make our healthcare systems safer:

A recent audit in the UK showed that, in some hospitals concentrated potassium chloride injection was still available on general wards, even after the alert. The NPSA had recently issued a safety alert requiring chief pharmacists to remove that product from wards. In spite of the numerous reports of errors involving concentrated potassium chloride injection, many pharmacists telephoned the NPSA to say that they had not had a problem. "What they mean is that they have not had a problem yet," warned Professor Cousins.

Thinking "That would never happen to me." might be OK when you are getting in your car and driving without a seatbelt, applying such thinking to other people's lives is not supportable, especially when you could predict the next potassium death in the papers with almost alarming regularity.
posted by Anthony Cox at 8:31 AM | permalink


Methotrexate Errors: Methotrexate is the vincristine of primary care (although admittedly problems exist with its use in hospitals too.). The NPSA are going to tackle it next.

"Guidance on the dispensing and administration of oral methotrexate is next on the medicines agenda of the National Patient Safety Agency, according to Professor David Cousins Head of Safe Medication Practice at the NPSA. "
posted by Anthony Cox at 8:26 AM | permalink

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Wednesday, June 11, 2003

Trials vs Real World: Although not directly about adverse reactions I thought this was an editorial that is worth a read:

"The interface between evidence and clinical care is complicated: What appears black and white in a trial report may "rapidly become grey in practice" . Even when presented with internally valid, well-conducted trials, clinicians frequently face doubts about how we can apply this evidence to our individual patients. The potential problems in extrapolating from trials that are small, are of short duration, rely on surrogate outcomes, or use active controls of uncertain efficacy are well described. However, in this editorial, I focus on the dilemma at the heart of Dr. Shlipak's paper in this issue : Can we extrapolate from trials conducted in highly selected subsets of patients to a broader population of patients who have the same condition but do not meet the trial eligibility criteria?"

Finlay A. McAlister in the Annals of Internal Medicine.
posted by Anthony Cox at 1:39 PM | permalink


Bye Bye BAN: "European law requires the use of international names (rINNs) for substances used in medicinal products and this requirement is also reflected in UK legislation. The UK has a well-established national naming system, the British Approved Name (BAN). As public health concerns were expressed about the potential for medication errors to occur if certain names were changed, use of the rINN has not been strictly applied in the UK. The MHRA in consultation with DH, the Devolved Administrations, and endorsed by independent advice from the Medicines Commission, proposes to implement the changeover to rINNs for virtually all medicinal substances where BANs are currently used with the exception of adrenaline and noradrenaline." MHRA proposal [PDF 83KB]
posted by Anthony Cox at 1:37 PM | permalink


Would Glaxo have said anything?: Professor Alasdair Breckenridge, chairman of the Medicines and Healthcare Products Regulatory Agency (MHRA), said evidence from nine studies of Seroxat in young people became available to the agency on 27 May. They showed an increased risk of suicidal thoughts and self-harm among those under 18 and that the drug was ineffective in treating depression in this group.

"The balance of risk and benefit is unfavourable. The drug should not be used in young people,'" he said.

Seroxat was licensed for adults in 1990 but has never been licensed for children and young people. Doctors have prescribed it to up to 8,000 under-18s in cases where they take personal responsibility.

The results of the nine studieswere submitted to the MHRA by GlaxoSmithKline, makers of Seroxat, as part of preliminary moves to obtain a licence for the drug to treat obsessive compulsive and social anxiety disorder in under-18s. The disclosure raises doubts over whether the risks would have come to light had GlaxoSmithKline not sought to extend its licence.

The Independent.
posted by Anthony Cox at 1:31 PM | permalink

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Tuesday, June 10, 2003

Paroxetine Safety Alert: Safety Alert issued by the DOH. Key points are:

1. Seroxat should not be prescribed as new therapy for patients under 18 years of age with depressive illness.

2. If your patient is being successfully treated with Seroxat, then the completion of the planned treatment course should be considered as an option in the management of the illness.

3. If your patient is not doing well on Seroxat, change of treatment should be considered.

When stopping treatment with Seroxat:

Seroxat should not be stopped suddenly because of the risk of withdrawal reactions. The dose should be reduced very gradually, using half tablets, and then alternating days, if necessary. If the dose is not tapered, there is a greater chance of experiencing side effects. For the majority of people, symptoms go away on their own within 2 weeks. If side effects are intolerable on dose reduction or stopping, the dose should be increased and subsequently reduced more gradually.

UPDATE: MHRA letter [PDF 89KB] and Questions and Answer sheet [PDF 49KB]

BBC Coverage and The Guardian.
posted by Anthony Cox at 10:03 AM | permalink

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Monday, June 09, 2003

Doing the write thing: Often medical notes are not as well written as they ought to be. For example, reasons for drugs being discontinued are not documented and the details of a new drug being started are not logged. The Times reports that some effort is being made to get people to document things in the medical notes.

Hospitals are spending hundreds of thousands of pounds a year teaching their doctors and nurses how to write better patient notes. Trainees taking a course on writing have been asked to provide examples of their work. One case read: "6.30am sleeping peacefully, 8.40am dead."

In another incident a member of staff was working in an accident and emergency department - where the abbreviation DOA meant "Dead on Arrival" - was transferred to a ward. He told a patient's relative: "I'm terribly sorry but your mother was dead on arrival." DOA meant "Date of Admission" on the ward notes.

posted by Anthony Cox at 9:48 PM | permalink


Seroxat Changes: "Experts are set to update the safety advice provided with the controversial antidepressant Seroxat. The drug has been at the centre of a storm amid claims that it is addictive and could increase the risk of violent behaviour in some patients.

It's maker, GlaxoSmithKline, insists that it is a safe drug - prescribed to thousands of patients in the UK. "

BBC News
posted by Anthony Cox at 9:42 PM | permalink

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Saturday, June 07, 2003

Report from Royal College of Physicians: A write up of the Problems and Perils of Prescription Medicines at the Royal College of Physicians has been published in the Pharmaceutical Journal.

A new system of classifying adverse reactions was proposed by Dr JEFF ARONSON, university department of clinical pharmacology, Radcliffe Infirmary, Oxford. He called the system "DoTS" because it involved classification according to: Dose-responsiveness, Timing and Susceptibility
posted by Anthony Cox at 8:08 AM | permalink

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Friday, June 06, 2003

Natural Disaster: "There has been recent media interest following a letter late last year to the medical journal, the Lancet, concerning a possible association between the herb Chelidonium majus (Greater celandine) and liver problems. Greater celandine, or chelidonium has been traditionally used to treat conditions of the liver and other conditions, and is widely available internationally. "

Therapeutic Goods Administration 5th June 2003
posted by Anthony Cox at 12:01 PM | permalink


Knowing when to stop drugs: "Polypharmacy remains an issue for elderly people and patients with complex needs. I was reminded of the need to look critically at all prescriptions, stopping any that are no longer required."
posted by Anthony Cox at 8:42 AM | permalink


Media to Quick to promote Mavericks: "The media love a maverick. That's one reason why a figure such as Dr Andrew Wakefield, who challenged established thinking over the measles, mumps, and rubella (MMR) vaccine, has received so much coverage in the British press. But although some newspapers have presented Wakefield as a popular hero, fighting scientific officialdom on behalf of parents worried about autism, nearly half of the public believes that journalists should have subjected his claims to more scrutiny before reporting them.

A study of what and how people learn about science from the media discovered that 48% of the public felt that when scientists go against the grain, as Wakefield did in suggesting a link between MMR and autism, the media should wait until other studies confirm those findings before covering them. Thirty-four per cent of the survey sample of more than 1000 people thought that the media should give such scientists prominent coverage and 18% expressed no opinion. "


Trevor Jackson, assistant editor BMJ
posted by Anthony Cox at 8:40 AM | permalink

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Wednesday, June 04, 2003

Prozac in the News: In the Guardian and the BBC webpages today.

Wendy Hay, 52, the wife of leading toxicology professor Alistair Hay, was found hanged at their home near Leeds in September last year.

Professor Hay, an expert in chemical and biological warfare and professor of environmental toxicology at Leeds University told an inquest today he believed she died because she was taking Prozac.


The MHRA recently announced a review of this class of drugs.

UPDATE: Coroner reports no proof of Prozac as cause of suicide
posted by Anthony Cox at 4:20 PM | permalink


Counterfeit Lipitor: The Food and Drug Administration announced that its continuing investigation of counterfeit Lipitor has turned up additional counterfeit quantities of the cholesterol-lowering pharmaceutical product.
posted by Anthony Cox at 2:10 PM | permalink


Causality Assessment: Assessing whether a drug has caused a adverse reaction is an important part of pharmacovigilance, but is fraught with difficulty. Although there are decisional algorithms which can be used to assess probability, perhaps the best known being the Naranjo algorithm, some are skeptical of the usefulness.

Macedo AF et al have published a paper which compared 15 algorithms to an expert panel opinion for 200 cases. Full agreement was not found for any level of causality assessment. Those that had confounding factors, i.e. one or more variables which are also risk factors for the event of interest (e.g. an underlying disease or concomitant medication), had the least agreement.

I've found causality algorithms useful personally, as they do make you think when looking at a case in a logical and methodical way if you have used them in the past.
posted by Anthony Cox at 9:44 AM | permalink

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Tuesday, June 03, 2003

Direct to Consumer Advertising (DTCA): European Union Health ministers have voted to uphold the ban on DTCA.

Jackie Glatter, spokeswoman for the Consumers' Association, said: "What patients need is high quality, independent, comparative information on medicines so that they are able to make informed choices about their health care."

"Today's decision sends a clear message to the pharmaceutical industry that drug promotion is not the same as good quality information. "

She said: "The government now needs to take steps to significantly improve patient information.

"It must also prevent further industry attempts to circumvent the ban."

posted by Anthony Cox at 4:00 PM | permalink


Thoughts on Medical Error: "The resultant explosion of pharmacological knowledge, relevant to safe prescribing, is beyond the capacity of the cleverest mind. Clinicians who are aware of this knowledge deficit (regarding drug action, unwanted sideeffects and harmful interaction of co-prescribed drugs) are now sharing difficult prescribing decisions with clinical pharmacists or using computerised prescribing support systems. Such wise practices remain a minority activity.

Secondly, despite the tenfold increase in pharmacological knowledge, most UK medical schools devote less teaching time to pharmacology and therapeutics than in the 1960s. Further, no doctor of any speciality (anaesthetics excepted) is obliged to pass an examination in therapeutics and pharmacology for the final primary medical degree or for any postgraduate qualification. "


HUGH McGAVOCK in the Times.
posted by Anthony Cox at 10:52 AM | permalink

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