Learn: Learnhttps://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/page/3/?d=1Learn: LearnenUnderstanding dispensing errors and risk (10 November 2020)https://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/understanding-dispensing-errors-and-risk-10-november-2020-r3688/3688Mon, 30 Nov 2020 13:22:00 +0000SMASH! The Salford medication safety dashboard (BMJ, 1 July 2018)https://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/smash-the-salford-medication-safety-dashboard-bmj-1-july-2018-r8280/ Based on initial system requirements, Williams et al. designed the dashboard’s user interface over three iterations with six GPs, seven pharmacists and a member of the public. Prescribing safety indicators from previous work were implemented in the dashboard. Pharmacists were trained to use the intervention and deliver it to general practices.

 A web-based electronic dashboard was developed and linked to shared care records in Salford, UK. The completed dashboard was deployed in all but one (general practices in the region. By November 2017, 36 pharmacists had been trained in delivering the intervention to practices. There were 135 registered users of the dashboard, with an average of 91 user sessions a week.

The authors have developed and successfully rolled out of a complex, pharmacist-led dashboard intervention in Salford, UK. System usage statistics indicate broad and sustained uptake of the intervention. The use of systems that provide regularly updated audit information may be an important contributor towards medication safety in primary care.

]]>8280Sun, 29 Nov 2020 09:25:00 +0000Explore England's prescribing datahttps://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/explore-englands-prescribing-data-r3628/3628Tue, 24 Nov 2020 16:38:00 +0000NHS England: Support for prescribershttps://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/nhs-england-support-for-prescribers-r5179/5179Tue, 22 Sep 2020 10:58:00 +0000The Salford Medication Safety Dashboard (SMASH)https://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/the-salford-medication-safety-dashboard-smash-r2567/2567Tue, 07 Jul 2020 09:31:00 +0000Drug-name confusion: reminder to be vigilant for potential errors (MHRA, 9 January 2018)https://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/drug-name-confusion-reminder-to-be-vigilant-for-potential-errors-mhra-9-january-2018-r9112/ Advice for healthcare professionals:

  • be extra vigilant when prescribing and dispensing medicines with commonly confused drug names to ensure that the intended medicine is supplied
  • if pharmacists have any doubt about which medicine is intended, contact the prescriber before dispensing the drug
  • follow local and professional guidance in relation to checking the right medicine has been dispensed to a patient
  • report suspected adverse drug reactions where harm has occurred as a result of a medication error on a Yellow Card or via local risk management systems that feed into the National Reporting and Learning System.
]]>9112Sun, 29 Mar 2020 18:33:00 +0000Patient Safety Authority Department of Health: Final recommendation to ensure accurate patient weights (8 September 2018)https://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/patient-safety-authority-department-of-health-final-recommendation-to-ensure-accurate-patient-weights-8-september-2018-r4046/ Having accurate patient information (for example, age, allergies, laboratory results) helps practitioners select medications, doses and routes of administration. One vital piece of information, the patient's weight, is especially important, because it is used to calculate the appropriate dose of a medication (for example, mg/kg, mcg/kg, mg/m2). A prescribed or dispensed medication dose can differ significantly from the appropriate dose because of missing or inaccurate patient weights.

Patients in oncology treatment, patients with renal insufficiency, or who are elderly, paediatric or neonatal are at greater risk for adverse drug events, because they are more vulnerable to the effects of an error, and their weight may change frequently over short periods of time. Formulas such as the Cockcroft-Gault equation, which is used to calculate creatinine clearance to aid in the dosing of medications, and the Harris-Benedict formula, which is used to calculate basal metabolic rate, rely on knowledge of an accurate patient weight. Also, both height and weight are needed to use nomograms to determine body surface area and body mass index, for example, when calculating doses for chemotherapy.

In the United States, most patients are weighed in pounds. But weighing and documenting patients' weights in pounds introduces the need to convert the weight into kilograms—an error-prone process—to conduct weight-based and other dosing. Another risk when measuring the patient's weight in pounds is failing to convert the weight into kilograms but recording that weight in kilograms (that is, documenting a weight of 200 lbs. as 200 kg instead of 90.9 kg), resulting in more than two-fold dosing errors.

This document recommends a number of procedures to ensure accurate patient weights.

Further reading

Weight-based medication errors: How to tip the scale in the right direction

]]>4046Sun, 16 Feb 2020 16:02:00 +0000WANDS – East Sussex Healthcare NHS Trust's medication administration checklisthttps://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/wands-%E2%80%93-east-sussex-healthcare-nhs-trusts-medication-administration-checklist-r718/ Wands.jpg.442675136ded34e98921f790518b5201.jpg

]]>718Mon, 07 Oct 2019 10:04:00 +0000Institute for Safe Medication Practices: Medication Safety Alert! Video - Episode 1 (July 2016)https://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/institute-for-safe-medication-practices-medication-safety-alert-video-episode-1-july-2016-r643/ Hear ISMP experts discuss medication safety concerns and offer practical error prevention recommendations in the Medication Safety Alert! Video Series, produced by ISMP in partnership with the Temple University School of Pharmacy.

This video focuses on:

  • findings from a summit on safe IV push medication use
  • new United States Pharmacopeia (USP) requirements to eliminate ratio expressions in drug labelling
  • ISMP’s latest Targeted Medication Safety Best Practices for Hospitals.
]]>643Fri, 20 Sep 2019 11:00:00 +0000Professional guidance on the administration of medicines in healthcare settings (January 2019)https://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/professional-guidance-on-the-administration-of-medicines-in-healthcare-settings-january-2019-r639/ The guidance is aimed at registered healthcare professionals; the principles however, can be applied in any healthcare setting by any persons administering medicines. The clinical elements of the prescribing of medicines (such as choice of medicine, treatment duration and method of administration) are beyond the scope of this guidance. The guidance applies across the UK.

]]>639Fri, 20 Sep 2019 09:26:00 +0000NICE/SCIE - Giving medicines covertly: A quick guide for care home managers and home care managers providing medicines support (2019)https://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/nicescie-giving-medicines-covertly-a-quick-guide-for-care-home-managers-and-home-care-managers-providing-medicines-support-2019-r330/ This quick guide includes information on:

  • capacity and consent,
  • what the process is if there is a decision to give medicines covertly, and
  • what to do if you need to make a decision urgently.
]]>330Fri, 02 Aug 2019 10:53:00 +0000Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility studyhttps://www.pslhub.org/learn/patient-safety-in-health-and-care/medication/medication-administration/effectiveness-of-a-%E2%80%98do-not-interrupt%E2%80%99-bundled-intervention-to-reduce-interruptions-during-medication-administration-a-cluster-randomised-controlled-feasibility-study-r289/ The study found nurses experienced a high rate of interruptions. Few were related to the medication task, demonstrating considerable scope to reduce unnecessary interruptions. While the intervention was associated with a statistically significant decline in non-medication-related interruptions, the magnitude of this reduction and its likely impact on error rates should be considered, relative to the effectiveness of alternate interventions, associated costs, likely acceptability and long-term sustainability of such interventions.

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