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    In the independent sector ranitidine 300mg visa, ensure that there is an auditable line of delegated authority from the board to the medication safety offcer and that the board retains the oversight responsibilities and oversees medication safety incident reporting and learning generic ranitidine 150 mg on line. The board director or superintendent pharmacist should foster a safety culture and satisfy themselves that proven 300mg ranitidine; these systems are operating effectively, the quality of incident reports supports learning, important patient safety issues identifed by these systems are adequately addressed locally and incident reports are submitted in a timely fashion for national learning. These individuals should have relevant knowledge and experience, and their current role should cover appropriate responsibilities. This may entail reviewing all medication incident reports to ensure data quality for local and national learning and where necessary to investigate and fnd additional information from reporters. The role of the medication safety committee An existing or new multi-professional committee should be identifed to support the safe use of medicines in the organisation. Defnition of a small healthcare provider organisation Any healthcare organisations not defned in section 7. Communication and support Receive support for reporting and learning from medication safety offcers in healthcare commissioning organisations and medication safety champions who are members of local professional committees and multi-professional committees. Medication safety champions Medication safety champions are individuals who have chosen to take an active role in improving the safe use of medicines. A safety champion will be someone who is already working to improve patient safety. Safety champions do not need to be appointed, however where champions are active organisations should try to capitalise on the contributions they can make. Defnition of healthcare commissioners Healthcare commissioning organisations purchase healthcare services. Clinical Commissioning Groups are responsible for commissioning secondary care and, depending on local arrangement, they may receive support from Commissioning Support Units. Both types of commissioners are responsible for improving quality and safety in primary and secondary care. The oversight role of clinical governance Invited arrangements for improving reporting and learning for medication error incidents should be part of clinical governance structures in commissioning organisations. These structures should ensure that medication error reporting systems are operating effectively, that the quality of incident reports supports learning, that important patient safety issues identifed by these systems are adequately addressed locally and that incident reports are submitted in a timely fashion for national learning. These individuals should have appropriate knowledge and experience and their current work is likely to cover broadly similar responsibilities. The role of the medication safety committee An existing or new multi-professional committee can help to support the safe use of medicines in the organisation. It should be made up of: • medical staff; • nursing staff; • pharmacy staff; • those in risk management and general management; and, • a patient representative. Some patient complaints may contain information about incidents involving medication errors. The overall number of medication incidents for each organisation is provided as part of this summary. Reporting and Learning System in England and Wales over six years (2005 – 2010) Br J Clin Pharmacol. Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency. Drug Safety Update is essential reading for all healthcare professionals, bringing them the very latest information and advice to support the safer use of medicines. Communications via the Central Alerting System • Safety warnings and messages about medicines Available at: www. This includes all reports received from healthcare professionals, members of the public and pharmaceutical companies. The objectives for the network are to: • improve reporting and learning of medication incidents by educating and training Medication Safety Offcers in patient safety science; and, • disseminate relevant research and information concerning new risks and best practice. Medication safety offcers will be invited to conferences/workshops, regular online Webex meetings, email discussion groups and online information forums to discuss topics identifed at local and national level.

    The staff of medical tourism facilitators‘ offices may be party to clinical information on patients ranitidine 300mg sale, and this private and sensitive information would need to be dealt with very carefully and there is potential for them to sell the information to other medical service companies discount ranitidine 300mg free shipping. This may not be available every time in the medical tourism setting generic ranitidine 300mg line, and it is possible that medical tourists may come to regret this if there are failings in professional or clinical practice (Pennings, 2004, Barclay, 2009, Jeevan et al. Infection and cross-border spread of antimicrobial resistance and dangerous pathogens 90. Of significance is the potential for hazardous micro-organisms transferring between hospitals located in different parts of the world on the body of a medical tourist (Green, 2008). The rapid spread of North American ―swine‖ flu out of the United States and Mexico to the rest of the world in 2009 and after illustrates the ease with which micro- organisms can be transported across borders. Anecdotally, one author (Green) is aware of cases where hepatitis B was acquired during cardiac surgery in Pakistan and renal transplantation in India. A study of medical tourists undergoing kidney transplants concludes there was inadequate communication of information regarding preoperative information and postoperative immunosuppressive regimens (Canales et al. Medical travellers may be travelling from home to countries with very different ecosystems and disease profiles, and in some destinations may encounter diseases such as malaria, dengue and other arthropod-borne infections. All people, whether medical travellers or not, who are travelling to different countries should be made aware of the potential for acquiring diseases and injuries which are not common in their own country. The lack of any routine data means there is little idea of how prevalent infections are or how they compare with rates from regular tourists. Quality maximisation and risk minimisation are two key ingredients for creating better and safer health care services, whether they are providing services for domestic consumption or for medical travellers. This can only be accomplished through the setting-up of appropriate forms of organisational framework within the hospital or clinic designed to assess quality, identify risk, and deal with all relevant issues, and at the same time promote a culture of remaining vigilant. At the present time, medical tourism 27 services remain largely unregulated and a huge issue that needs to be faced up to is whether or not the quality and safety standards on offer through medical tourism are to be trusted. Concerns for the quality and safety of the medical care provided overseas have also emerged due to the lack of robust clinical governance arrangements and quality assurance procedures in provider organisations, intended to safeguard the quality of care provided to tourists (Zahir, 2001). There have also been questions over the training, qualifications, motivations and competence of health care professionals. In response to such concerns, a range of independent accreditation schemes have been established with the aim of assuring the care of medical tourists in a way that avoids potential conflicts of interest. Groups such as the Joint Commission International from the United States (covering 44 countries: http://www. Common characteristics of all accreditation schemes are:  Surveys and reviews conducted by professional peers with appropriate training;  The means should be put into place by which problems can be identified prospectively and corrected and continuous improvement ensured;  A mechanism within the accreditation process for ensuring follow-up action takes place on any recommendations that arise from the survey and for correcting any problems identified by the measurement process; and  The assessment process should be repeated periodically, usually between two to four years. Accreditation has come to be thought of as a ―stamp of approval‖ verifying the authenticity and quality of the services provided. Potential problems with accreditation include:  The commercial needs and aspirations of the accreditation schemes themselves may be allowed to dominate the picture. Many (but not all) of the accreditation schemes operating internationally are private companies or corporations. Standards are at the heart of accreditation, and they must be directed towards those factors that may make a difference to the quality of care. Accreditation schemes should be fit for purpose, based on the results of the best available research, and sensitive to change. There are therefore three categories of area where accreditation is of interest to the medical tourism market: a) Offering assurance to commercial interests of the quality and safety of the product they are selling to the public, which in turn may reduce their liability and minimise bad publicity in the future. Currently, there is no universal ―official agency/group‖, such as the United Nations, the World Health Organization, the World Tourism Organization or the World Trade Organization, engaged in either the delivery of accreditation, the co-ordination of delivery of accreditation, or licensing or studying the existing schemes that deliver accreditation. Mandatory accreditation may appeal to governments and commercial healthcare purchasers such as third-party payers (e. Accreditation has most often been used as a marketing tool by wealthier provider hospitals, medical tourism facilitators and the governments of provider countries seeking to grow their share of the medical tourism business.

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    In these circumstances purchase ranitidine 150mg line, the need for additional therapy should be performed and treatment administered accordingly discount ranitidine 300mg free shipping. Even after retreatment trusted ranitidine 300mg, serologic titers Management of Sex Partners might fail to decline. Special Considerations Syphilis During Pregnancy Penicillin Allergy All women should be screened serologically for syphilis early The efficacy of alternative nonpenicillin regimens in in pregnancy (106). Antepartum be ensured should be desensitized and treated with penicillin screening by nontreponemal antibody testing is typical, but (See Management of Persons Who Have a History of treponemal antibody testing is being used in some settings. Any woman who has a fetal death after 20 weeks’ Follow Up gestation should be tested for syphilis. For women with a history of obstetric attention after treatment if they notice any fever, adequately treated syphilis who do not have ongoing risk, contractions, or decrease in fetal movements. Women without a history a rare complication of treatment, but concern for this of treatment should be staged and treated accordingly with a complication should not delay necessary treatment. If the woman is at low risk for syphilis, • Missed doses are not acceptable for pregnant women lacks signs or symptoms of primary syphilis, has a partner receiving therapy for late latent syphilis (423). Pregnant with no clinical or serologic evidence of syphilis, and is likely women who miss any dose of therapy must repeat the full to follow up, repeat serologic testing within 4 weeks can be course of therapy. If follow-up is not possible, women without a history of treated syphilis should be treated according to the Coordinated prenatal care and treatment are vital. Serologic titers can be checked Treatment monthly in women at high risk for reinfection or in geographic Penicillin G is the only known effective antimicrobial for areas in which the prevalence of syphilis is high. Providers preventing maternal transmission to the fetus and treating fetal should ensure that the clinical and antibody responses are infection (443). Evidence is insufficient to determine optimal, appropriate for the patient’s stage of disease, although most recommended penicillin regimens (444). Inadequate maternal treatment is Recommended Regimen likely if delivery occurs within 30 days of therapy, clinical signs Pregnant women should be treated with the penicillin regimen of infection are present at delivery, or the maternal antibody appropriate for their stage of infection. Management of Sex Partners Other Management Considerations See Syphilis, Management of Sex Partners. For women who have primary, secondary, or early latent syphilis, a second dose of Penicillin Allergy benzathine penicillin 2. Pregnant women who • When syphilis is diagnosed during the second half of have a history of penicillin allergy should be desensitized and pregnancy, management should include a sonographic treated with penicillin. However, this dose challenge might be helpful in identifying women at risk evaluation should not delay therapy. Sonographic signs of for acute allergic reactions (see Management of Persons Who fetal or placental syphilis (i. Erythromycin accompanied by these signs should be managed in and azithromycin should not be used, because neither reliably consultation with obstetric specialists. Data insufficient to recommend specific regimens for are insufficient to recommend ceftriaxone for treatment of these situations. Additional testing at for stillborn infants, skeletal survey demonstrating typical osseous 28 weeks’ gestation and again at delivery is warranted for lesions might aid in the diagnosis of congenital syphilis. Moreover, evaluation and treatment of neonates born to women who as part of the management of pregnant women who have have reactive serologic tests for syphilis during pregnancy. Routine screening of newborn sera or the neonate for congenital syphilis in most scenarios, except umbilical cord blood is not recommended, as diagnosis at when congenital syphilis is proven or highly probable (See this time does not prevent symptomatic congenital syphilis in Scenario 1). No mother or newborn infant should leave Scenario 1: Proven or highly probable congenital the hospital without maternal serologic status having been syphilis documented at least once during pregnancy, and preferably again at delivery if at risk. Other causes of elevated values should be considered when an immunoglobulin (IgM) test can be recommended. Data are insufficient regarding the use of Before using the single-dose benzathine penicillin G regimen, other antimicrobial agents (e.

    Cannabis resin Europe and North Africa Global cannabis resin seizures reached a record of 1 buy 150 mg ranitidine,648 Spain continued to report the largest annual seizures of mt in 2008 buy generic ranitidine 150 mg, and in 2009 declined to 1 purchase ranitidine 300mg otc,261 mt - a level cannabis resin worldwide. Every resin are trafficked from the source country of Morocco year from 2001 onwards, West and Central Europe, the to Spain, and on to other countries in Europe. Distribution Absolute values 100% 1,800 90% 1,600 80% 1,400 70% 60% 1,200 50% 1,000 40% 800 30% 600 20% 10% 400 0% 200 0 Near and Middle East/ South-West Asia Rest of the world Global total North Africa West & Central Europe West & Central Europe Near and Middle East /South-West Asia North Africa 45 This figure represents an aggregate of 624 kg of cannabis herb Rest of the world together with 11,042 seeds or bags, converted assuming a weight of half a gram per unit. In Algeria and Egypt, 500 200 seizures more than doubled in 2008, reaching a record 400 level of 38 mt in Algeria and a level of 12. Algeria reported that in 2009 cannabis 0 0 resin and cannabis herb in its territory originated entirely in Morocco. Quantity (mt) Seizure data and, to some extent, price data support the Number of seizures flow of cannabis resin from North Africa into western Europe via Spain. Apart from Spain, which reports the seizures of cannabis resin in Spain fell to 445 mt – the largest cannabis seizures in Europe by far, the largest lowest level since 1999 (431 mt) - while seizures in seizures among European countries in 2009 were Morocco rose from 114 mt in 2008 to 188 mt in 2009 reported by France and Portugal, followed by Italy and – the highest level on record. The decrease in seizures in Spain in 2009 was 2009, approximately one half of significant individual reflected in similar decreases in the four European coun- drug seizures reported by Spain involved cannabis resin. Seizures in However, Morocco is likely not the only source country Belgium have fluctuated considerably, amounting to for cannabis resin reaching Europe, and Spain assessed 18. In 2008, almost one half of cannabis resin cannabis resin in Pakistan originating seizures in the Americas were made by Canada (899 kg). Moreover, the traffick- 100 600 ing routes for cannabis resin reaching Canada appeared 90 to undergo significant changes. Canada identified the 500 Caribbean, North Africa and South-East Asia as the 80 70 origin for cannabis resin reaching its territory in 2008, 400 but these were replaced by Southern Africa and South- 60 West Asia in 2009. The United States also assessed that, 30 in 2008, cannabis resin was trafficked both to the United 20 100 States via Canada (from North Africa), and to Canada 10 via the United States (of Caribbean origin). Seizures of 0 0 cannabis resin in Mexico rose from 6 kg in 2007 to 297 kg in 2008 – the highest level since 1995. In Brazil, cannabis resin Quantity (tons) seizures tripled between 2006 and 2008, reaching the Number of seizures record level of 301 kg in 2008, but fell to 204 kg in 2009. Cannabis resin was further distributed from India to other destinations via cargo couriers. Near and Middle East/South-West Asia Seizures of cannabis resin in Pakistan rose for two years running, reaching 205 mt in 2009 – the highest level since 1995. Pakistan continued to assess the share of cannabis resin originating in Afghanistan at 98%. Over the period 1999-2009, 41% of significant individual drug seizures reported by Pakistan involved cannabis resin; the country of origin for these consignments was identified almost exclusively as Afghanistan. In the Islamic Republic of Iran, seizures of cannabis resin fell twice in succession, from the record level of 2007 (90 mt) to 69 mt in 2009. Based on data for the first nine months of the year, it appears that the decreas- ing trend continued into 2010. The Islamic Republic of Iran assessed that, in 2009, one quarter of cannabis resin trafficked on its territory was intended for the country itself, with the remainder intended for Arab countries, Turkey and Europe. Seizures in Afghanistan fell from the record level of 2008 (271 mt) to the relatively low level of 10. Neverthe- less, Canada has a significant consumer market for can- 200 The cannabis market Fig. Figures in brackets represent the upper and lowest and highest provincial price observed.

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