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E-Newsletter March 2006

Topics in this Dawn AC E-Newsletter Previous Newsletters

Confusion with Tablet sizes

Improving the Safe Use of Anticoagulant Therapy - Reminder

Free Quality of Care Guide and Safety Checklist Guide

Customer Survey 2006

Demand for Web Browser Version 7 High

British Society of Haematology Annual Scientific Meeting, 3 - 5 April 2006, EICC, Edinburgh

Confusion with Tablet Sizes

Extract From 'Daily Mirror' 25^th Feb 2006 - Agony Of Drug Error Grandmother

"A blind gran spent her final weeks in agony after a nursing home gave her 10 times the correct dose of her medicine.

Florence Bell, 80, was left with severe bruising and internal pain after spending three weeks on the wrong level of bloodthinning pills.

An error at the Portsmouth home meant she got 5mg rather than 0.5mg of heart drug warfarin - also used as rat poison.

A hospital spotted the blunder but she died a week later of unrelated heart failure. Grandson Paul Goodale, 26, said: "I was shocked and angry."

The council has beefed up checks since her death in December. Social services chief Rob Watt said: "This is regrettable.""

Improving the Safe Use of Anticoagulant Therapy - Reminder

The UK National Patient Safety Agency (NPSA) has recently published a Risk Assessment of Anticoagulation Therapy.

The NPSA contacted the medical and pharmacy defence organisations as well as the NHS Litigation Authority.

There have been 600 patient safety incidents of harm or near harm associated with the use of anticoagulants in the UK between 1990 and 2002. Of these cases, 20% (120) have resulted in the death of the patient.

Death associated with the use of warfarin is responsible for 77% (92 reports) and death associated with heparin is responsible 23% (28 reports).

Further analysis of the data from the Medical Defence Union (MDU) was possible. Fatal incident reports from this source concerning warfarin made up 88% (79 reports) of the total 92 reports.

Deaths associated with the use of warfarin in primary care were 76% (60 reports) of the total reported to the MDU (79 reports). The main types of causes for these fatal incidents were:

1) inadequate laboratory monitoring; and 2) clinically significant drug interactions usually involving non-steroidal anti-inflammatories.

The Medical Defence Union has also informed the NPSA that the number of negligence claims involving anticoagulants has increased since 1990.

This report is available at http://saferhealthcare.org.uk

You need to register and then take the following menu options: Communities, Discussion Groups, Medication Safety, and 'Anticoagulants (e.g. Warfarin and Heparin products)' from the list of discussion issues.

The deadline for comment on the Assessment and supporting documents is the 31^st March 2006.

Free Quality of Care Guide and Safety Checklist Guide

A short free booklet available on request from our website provides guidelines for the safe operation of computer aided software. It describes some of the incidents that have occurred over the years with computer software and provides checklists to help you prevent mistakes with computer-aided software.

Go to http://www.4s-dawn.com/dawnac/qualcare.htm and complete the form and we will forward you a copy of the checklist.

Demand for Web Browser Version 7 High

The demand for the Web Browser version of Dawn AC is high. Since December, over 40 centres have expressed an interested in upgrading from Version 6 and currently three large centres are now operational and several centres are the process of migrating their data. If you are interested please don't delay in requesting a quotation.

Customer Survey 2006

We need to know what you think our products and services so that we can supply you with 'what you really want'. You should all have received a short questionnaire. Thank you to those who have already completed the survey. If you have not done so please spend a few minutes to complete and return the form.

British Society of Haematology Annual Scientific Meeting, 3 - 5 April 2006, EICC, Edinburgh

Please come visit our booth at the BSH meeting Edinburgh. You will see the new web browser version of Dawn AC and our plans for enhancing our Clinical Haematology/Multi-Disciplinary software.

Syd Stewart

Managing Director

End of Newsletter

“We Really Care"

“Dawn AC is an easy to use, adaptable, powerful, and comprehensive PC based Anticoagulation Software System. It covers the complete oral anticoagulation life cycle with Induction and Maintenance Modules “

“Lancet Nov 7th 1998, Multi-centred Randomised Trial using Dawn AC shows computer aided dosage leads to INR control 20 to 30% better than medical experts”