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Showing results for tags 'Adminstering medication'.
Found 168 results
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Content Article
People with Parkinson’s need their medication on time every time. Yet over half of people with the condition don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death. Parkinson's UK are campaigning to make sure that no one with Parkinson’s is worried that they will leave hospital more unwell than when they went in. Whether you have Parkinson’s, support someone who does, work in the health and care system or campaign to improve it, you can take action to make hospitals and care homes safer. Together we can get more people to understand how big this problem is. And we can put pressure on the right people, across the UK, to change hospital policies, improve prescribing in hospitals and make sure staff are trained to give time critical medication. -
Content ArticleThe Patient Safety Network (PSNet) produces primers which provide guidance on key topics in patient safety through context, epidemiology and relevant PSNet content. This primer focuses on nurse-related medication administration errors and highlights that despite error reduction efforts through implementing new technologies and streamlining processes, medication administration errors remain prevalent. It covers the background to the issue, low-tech and high-tech prevention strategies and the current context.
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News Article
Trust given warning notice over rapid tranquillisation
Patient Safety Learning posted a news article in News
A mental health trust has been served with a warning notice ordering improvements in its processes around rapid tranquillisation of patients. The Care Quality Commission said the trust needed to ensure all staff at Kent and Medway NHS and Social Care Partnership Trust followed local and national recommendations to monitor and record a patient’s physical health when rapid tranquillisation was administered. Inspectors were concerned staff were not always aware of the potential impact of these medications. Serena Coleman, CQC deputy director of operations in the south, said: “We found some staff weren’t always using the least restrictive options to make sure that people’s behaviour wasn’t controlled by an excessive use of medicines. “As required medication, such as lorazepam and promethazine, was being used quite frequently but we couldn’t always find records to explain why these medications were necessary. There were examples where reviews hadn’t happened for long periods, meaning staff couldn’t be sure it was still appropriate to administer to people." Read full story (paywalled) Source: HSJ, 3 August 2023 -
Content ArticleRizwana Dudhia shares in the Pharmaceutical Journal how a project she initiated to prevent the prescribing of inappropriate medication improved the quality of life for patients with learning disabilities and autism.
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Content Article
Better use of data for medication safety in hospitals
Kenny Fraser posted an article in Medicine management
NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. In this blog, Kenny Fraser, CEO of Triscribe, explains why we need to deliver quick, low-cost improvement using modern, open source software tools and techniques. We don’t need schemes and standards or metrics and quality control. The most important thing is to build software for the needs and priorities of frontline pharmacists, doctors and nurses. -
Content ArticleMedication error may occur for a variety of reasons. One of the most common sources of medication error is related to look-alike and sound-alike (LASA) drugs as well as the often-similar appearances of the vials. LASA medications are typically thought of as medications that are similar in physical appearance related to packaging as well as medications whose names are similar in spelling or in the phonetic pronunciation. Tricia A. Meyer looks at cases of LASA drugs and prevention techniques. She concludes that healthcare professionals, safety groups, and professional organisations should continue to work with manufacturers, regulators, and naming entities to explore opportunities to minimise the LASA risks for drugs that are either new to the market or in the pre-marketing stage. Further information on the hub Take a look at our Error traps gallery on the hub
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Content ArticleElectronic prescribing (ePrescribing) systems allow healthcare professionals to enter prescriptions and manage medicines using a computer. Sheikh and colleagues set out to find out how these ePrescribing systems are chosen, set up and used in English hospitals. Given that these systems are designed to improve medication safety, we looked at whether or not these systems affected the number of prescribing errors made (mistakes such as ordering the wrong dose of medication). They also tried to see whether or not the systems were good value for money (or more cost-effective). Finally, they made recommendations to help hospitals choose, set up and use ePrescribing systems.
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Content ArticleThere is little longitudinal information about the type and frequency of harm resulting from medication errors among outpatient children with cancer. This study aimed to characterise rates and types of medication errors and harm to outpatient children with leukaemia and lymphoma over 7 months of treatment.
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Content ArticleIn this study, Hawkins and Morse explored nurses’ work in the context of medication administration, errors and the organisation. Secondary analysis of ethnographic data included 92 hours of non-participant observation, and 37 unstructured interviews with nurses, administrators, and pharmacists. Think-aloud observations and analysis of institutional documents supplemented these data. Findings revealed the nature of nurses’ work was characterised by chasing a standard of care, prioritising practice and renegotiating routines. The rich description identified characteristics of nurses’ work as cyclical, chaotic and complex, shattering studies that explained nurses’ work as linear. A new theoretical model was developed, illustrating the inseparability of nurses’ work from contextual contingencies and enhancing our understanding of the cascading components of work that result in days that spin out of the nurses’ control. These results deepen our understanding why present efforts targeting the reduction of medication errors may be ineffective and places administration accountable for the context in which medication errors occur.
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Content ArticleThis study by a team at the University of Derby in the British Journal of Anaesthesia used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task. The authors found that errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays, a finding that was replicated for correct responses for error-absent trays. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.
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News ArticleHigh risks relating to the ordering, prescribing, storing and administration of medicines have been found by the Mental Health Commission in a series of inspections of mental health centres in Dublin. The commission emphasised the need to have appropriate practices including the recording of the minimum dose interval information; where medication has been stopped, the stop date to be recorded; and the need to always have the prescriber’s signature recorded. The inspector of mental health services Dr Susan Finnerty said it was positive to see centres maintaining high compliance rating, but spoke of concerns around the administration of medication. “We know that medication is an important tool in treatment of mental illness. In order to reduce the risk of medication errors, we need to be sure that medication prescription and administration records are completed correctly,” Dr Finnerty said. Read full story Source: Independent Ireland, 18 January 2023
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Content ArticleThis blog by Dr Anna Bayes from Altera Digital Health looks at the benefits of closed-loop medication administration (CLMA) in preventing avoidable medication errors. CLMA provides an extra validation at the point of drug administration by using barcode technology to positively identify the patient and validate their prescribed medications against the physical medication product (for example, pills, infusions or creams) at the point of care. Anna also considers CLMA's role in advancing digital maturity.
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Content Article
Deprescribing. 'Do I really need this medicine?'
Patient Safety Learning posted an article in Medicine management
Overprescribing effects patient’s experience of, and engagement with, health and care services. It results in unnecessary costs and harm to patients. Watch this short video from Steve Turner. Reflection and key learning points based on UK laws and guidelines. -
Content ArticleIn 1999, the pivotal report “To Err is Human” by the Institute of Medicine led to sweeping changes in healthcare. This report outlined how blaming individuals does not change the underlying factors that contribute to medical errors. It also stated that blaming an individual does little to make the system safer – or prevent someone else from similar errors. It is unusual for a nurse to be charged criminally, when there is no intent to harm a patient. However, the recent trial in America of nurse RaDonda Vaught could set a precedent for future medical errors to be treated as criminal cases. The case may ensure that for every step that has been taken forward in patient safety, we have now taken two steps backwards. This article from Human Factors 101 looks at the case of RaDonda Vaught, the criminal trial and conviction, and discusses the impact this will have on healthcare.
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News ArticleDoctors have criticised new health secretary Therese Coffey over reports that pharmacists will be allowed to prescribe antibiotics without the approval of a doctor. According to The Times, Ms Coffey’s “Plan for Patients” will give pharmacists the power to prescribe certain drugs, such as contraception, without a prescription in an effort to reduce the need for GP appointments and tackle waiting lists. Responding to reports of the plans, Rachel Clarke, an NHS palliative care doctor and writer, wrote on Twitter: “This is staggeringly irresponsible of Therese Coffey and will cause so much more harm than good. “Doctors do not – unlike Coffey – dish out spare antibiotics to our family and friends because we’re painfully aware of the harms of antibiotic resistance. Utter recklessness.” Stephen Baker, a professor at Cambridge University and an expert in molecular microbiology and antimicrobial resistance, branded the health secretary’s plans “moronic”. He told the newspaper that the more antibiotics were used “the more likely we are to get drug-resistant organisms”. He added that it was “nuts” to consider widening access to drugs, adding that resistance against antibiotics is “clearly one of the biggest problems humanity is facing in respect of infectious disease at the moment”. Read full story Source: The Independent, 17 October 2022
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Content ArticleThe Australian Institute of Health Innovation conducts world-class research to catalyse health service and systems improvements in Australia and internationally. Its research generates highly practical evidence-based recommendations and information that health services can implement or use now. The Health Innovation Series supports clinicians, hospitals, policy makers and developers to apply this evidence to enhance the health system and services. The Health Innovation Series communicates research evidence in an easy-to-read, short format with clear recommendations, covering a wide range of topics.
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News Article
Drug shortages linked with medication errors, study results suggest
Patient Safety Learning posted a news article in News
A French study of adverse drug reactions has a highlighted a link between drug shortages and medication error. Data from the French Pharmacovigilance Database show that medication errors were identified in 11% of the 462 cases mentioning a drug shortage. The researchers found that medication errors usually occurred at the administration step and involved a human factor. “A drug shortage may lead to a replacement of the unavailable product by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labelling, dosage and sometimes a different route of administration that may increase the risk of a medication error.” Read full story (paywalled) Source: The Pharmaceutical Journal, 11 October 2022 -
Content ArticleThe National Medication Safety Symposium was held in Sydney, Australia, in support of World Patient Safety Day. The presentations from the 2-day conference can be viewed on YouTube from link below.
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Content ArticleThe World Health Organisation's third World Patient Safety Day took place on 17 September. This year’s theme was medication safety. In this blog, Clare Wade, Assistant Director of Casework at the Parliamentary and Health Service Ombudsman (PHSO) discusses the impact of medication errors and gives examples of poor practice.
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News ArticleMany pharmacies and physicians are forced to deny patients access to drugs, such as methotrexate, that can be used to help induce an abortion A few weeks after the supreme court’s 24 June decision to overturn the nationwide abortion rights established by Roe v Wade, the pharmacy chain Walgreens sent Annie England Noblin a message, informing her that her monthly prescription of methotrexate was held up. Noblin, a 40-year-old college instructor in rural Missouri, never had trouble getting her monthly prescription of methotrexate for her rheumatoid arthritis. So she went to her local Walgreens to figure out why, standing in line with other customers as she waited for an explanation. When it was finally her turn, a pharmacist informed Noblin – in front of the other customers behind her – that she could not release the medication until she received confirmation from Noblin’s doctor that Noblin would not use it to have an abortion. Since the supreme court’s elimination of federal abortion rights, many states have been enacting laws which highly restrict access to abortion, affecting not only pregnant women but also other patients as well as healthcare providers. As a result, many pharmacies and physicians have been forced to deny and delay patients’ access to essential medications – such as methotrexate – that can be used to help induce an abortion. Noblin is one of the 5 million methotrexate users across the US and one of the country’s many autoimmune patients. Although she was eventually given her prescription, Noblin and other patients are now forced to grapple both with a monthly invasion of privacy at pharmacies that ask them about their reproductive choices as well as the possibility of being wholly denied the medication in the future due to restrictive laws. Read full story Source: The Guardian, 26 September 2022
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Content ArticleDuplicate medication orders are a prominent type of medication error that in some circumstances has increased after implementation of health information technology. Duplicate medication orders are commonly defined as two or more active orders for the same medication or medications within the same therapeutic class. While there have been several studies that have identified contributing factors and described potential solutions, duplicate medication order errors continue to impact patient safety.
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Content ArticleThis guide is designed to support healthcare providers when talking to patients about the use of of oxytocin to start or advance labour.
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Content Article
This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus 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 six top Learn articles about medication safety in social care. -
Content ArticleAccording to the World Health Organization (WHO), medication harm accounts for 50% of the overall preventable harm in medical care. As well as telling the story of Melissa Sheldrick, who has been campaigning to improve medication safety since her son Andrew died as a result of a medication error, this blog looks at how making it 'safe-to-say' can reduce the risk of medication errors. Healthcare systems need a culture shift that makes it safe-to-say when something has gone wrong, is going wrong, or could go wrong. The authors argue that it is only when errors are appropriately managed, reported, responded to and learned from that we can improve the system as a whole, support people impacted to heal and take informed action to prevent similar incidents from happening in the future.
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Content ArticleSpecialist inspectors have identified cases of Salbutamol inhaler overprescribing of up to six inhalers per prescription by online prescribers. This article explores the risks of prescribing high volumes of Salbutamol inhalers. It highlights the need for ongoing patient monitoring, counselling advice, inhaler device choices and discuss the clinical considerations when continuing treatment.
