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Patient Safety Learning

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  1. Gallery Image

    Filing

    Patient Safety Learning

    Patient Safety Learning posted a gallery image in Documentation

    Filing
    Although the drawers in this filing cabinet are labelled there is no standardisation to it. How easy is to find the drawer you want if you are in a hurry?
  2. Gallery Image
    Filing cabinet
    Untidy filing. Documents not always put away. Paper falling out of cabinet. This can makes finding documents slow and time consuming and open to error if a document is put in the wrong drawer or lost.
  3. Gallery Image
    Storage trays
    These fluids stored here are all different. Although labelled, how easy is it to pick up the wrong one? Look at the red labels - is the label for the tray above or below?
  4. Gallery Image
    Fluid storage
    The trap here is that the fluids stored here are all different. There is a normal saline stored next to potassium and glucose. In a hurry, the wrong fluid may be picked up and cause patient harm or even death.
  5. Gallery Image
    Prednisolone tablets
    Same medication but different doses. Easy to pick up the wrong box if in a hurry.
  6. Gallery Image
    Noradrenaline and Dexamethasone
    Almost identical packaging and labelling.
  7. Gallery Image
    Metoprolol tartrate
    Same drug, but different bottles...
  8. Gallery Image
    Metoclopramide and Pitocin
    Very different drugs, so why the similar bottles?
  9. Gallery Image
    Boxes of Lisinopril
    Lisinopril tablets. Spot the pack with different dose. Very similar colours (purple and dark blue) to distinguish between 10mg and 20mg. Easy to pick up wrong pack if in a hurry.
  10. Gallery Image
    Heparin sodium and Midazolam
    Identical bottles, different medication.
  11. Gallery Image
    fentanyl v sux
    One drug is a strong pain killer used in anaesthetics (Fentanyl). The other is also used in anaesthetics and is a paralysing agent (Suxamethonium). Both look the same, same dose. Very dangerous if the wrong one is given to patient.
  12. Gallery Image
    Fentanyl and glyceryl trinitrate
    Different colour rings at top of the bottles are very easy to get mixed up.
  13. Gallery Image
    Ephedrine hydrochloride and Suxamethonium chloride
    Similar boxes, different drugs.
  14. Gallery Image
    Digoxin Teva
    Same packaging and text. Why isn't the dose in a different colour so it easily stands out? Busy staff have to look very closely at the boxes to identify the difference. Mistakes could easily be made.
  15. Gallery Image
    Similar bottles
    Almost identical bottles. Same colours used on both but different drugs.
  16. Gallery Image
    Ciprofloxacin and Clarithromycin
    Almost identical bottles, same colours used for both, similar names, same dosage. How easy would it be to pick the wrong one up?
  17. Gallery Image
    Ipratropium bromide and Salbutamol
    They look identical but different drugs. Often stored in the same place. Not catastrophic for most patients if they were given by mistake but would be for patients who were allergic.
  18. Gallery Image
    Atropine sulfate and Lidocaine HCL
    Similar bottles, but different drugs. Why are the caps the same colour?
  19. Gallery Image
    Tetracaine
  20. Gallery Image
    Prescription
    An example of poor prescribing. Would you be happy to administer this medication?
  21. Gallery Image
    Handwriting
    Can you read the notes?
  22. Gallery Image
    Handwriting
    Illegible writing.
  23. Gallery Image
    Prescription
    Guess what drug is being prescribed here...
  24. Content Article
    The objective of this investigation was to explore the care of patients who have ureteric stents inserted following a diagnosis of a kidney or ureteric stone. A ureteric stent is a narrow tube that is inserted into the ureter (the tube that connects the kidney to the bladder) to help with urine drainage. The reference event investigated was a woman who suffered an episode of kidney stones which was treated successfully but required the insertion of a ureteric stent. The stent was left in situ (in position) for a longer period than intended and became encrusted – that is, minerals filtered from the bloodstream attached to and built up on the stent. This led to the patient needing a more extensive operation to remove the stent. The findings and conclusions aim to prevent the future occurrence of unplanned delayed removal of stents and improve care for patients across the NHS.
  25. Content Article
    Tools are useful when working to become a high reliability organisation, but they do have their downsides. The Institute for Healthcare Improvement's Kedar Mate explains.
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