Top picks: Medication safety in hospitals

Summary

The World Health Organization’s annual World Patient Safety Day on 17 September 2022 focused on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm.

Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list 8 helpful reads related to medication safety in hospital settings.

Content

1 Error trap gallery - medication

the hub’s error trap gallery provides a place to share examples of error traps you come across in your day to day work, including error traps relating to medications. An error trap is a situation that could lead to avoidable harm if not mitigated. It is a situation where the circumstances work alongside human limitations to make errors more likely—for example, packaging design that makes it hard to distinguish one medication from another. Medications with similar packaging are one of the most common error traps in busy hospitals, and being aware of them can help reduce the risk of mistaking one medicine for another.

2 Healthcare Safety Investigation Branch investigation report: Unintentional overdose of paracetamol in adults with low bodyweight (24 February 2022)

The Healthcare Safety Investigation Branch (HSIB) carries out investigations into incidents of harm to gather and share learning that may help prevent similar errors happening again. In this investigation report, they look at the case of an 83-year-old woman who developed paracetamol-induced liver toxicity as a result of being overprescribed paracetamol while in hospital. The report presents key findings and safety observations around prescribing paracetamol to underweight adults. 

HSIB reports on a wide range of medication errors, and you can access all of their reports on the hub.

3 Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT

Antibiotic underdosing is a widespread issue in the healthcare system. The use of modern infusion pumps to deliver intravenous (IV) medications has resulted in the practice of flushing IV lines being lost in some specialties. Failure to give full doses of IV antibiotics poses significant risks to individual patients as well as adding to the problem of antimicrobial resistance (AMR). In this interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT.

4 Blog - Unit-dose medicines distribution for hospital inpatients

In this blog, independent pharmaceutical consultant Laurence Goldberg discusses the effectiveness and the potential for harm of unit-dose medicines distribution, often used in hospital settings as a way to save clinical staff time. In unit-dose dispensing, medication is dispensed in single doses in packages that are ready to administer to the patient. It can be used for medicines administered by any route, but oral, parenteral, and respiratory routes are especially common. Laurence highlights that although more research is needed, published studies have reported reductions in medication errors with unit-dose dispensing when compared with alternative dispensing systems such as ward stock systems.

5 Blog - Action needed make insulin administration in hospitals safer

This blog by Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents.

6 PSNet - Medication safety events related to diagnostic imaging (8 July 2022)

This case report by Patient Safety Network in the US looks at the benefits and risks of using sedative medication in patients undergoing diagnostic imaging such as an MRI scan. It looks at two separate cases where sedation was used so that the patient could tolerate having a scan, one of which resulted in the patient being intubated for several days due to severe acute respiratory distress syndrome as a result of aspiration while in the MRI machine.

7 Parkinson's UK: Time critical medication resources for health professionals

Patients with Parkinson’s are at risk of significant harm if they don’t get their medication on time, every time. ‘On time’ means within 30 minutes of the patient’s prescribed time. Even short delays can worsen symptoms such as rigidity, pain and tremors, increasing the risk of falls. Over half of people with Parkinson’s don’t get their medications on time, every time in hospital. This leads to worse patient outcomes, longer recovery times and increased costs to the NHS. Parkinson’s UK is working collaboratively to improve the delivery of time critical Parkinson's medications and have a number of resources to support healthcare professionals.

8 National campaign aims to reduce patient harm from infiltration and extravasation

Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and  cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and  extravasation and reduce avoidable harm. In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety.  

Take a look at our Top picks: Patient engagement for medication safety