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Showing results for tags 'Adminstering medication'.
Found 168 results
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News Article
Doctor struck off for ‘repeated dishonesty’ over death of child in 1995
Patient Safety Learning posted a news article in News
A doctor who attempted to cover up the true circumstances of the death in 1995 of a four-year-old patient has been struck off. Consultant paediatric anaesthetist Dr Robert Taylor dishonestly misled police and a public inquiry about his treatment of Adam Strain, who died at the Royal Belfast Hospital for Sick Children, a medical tribunal found. The youngster was admitted for a kidney transplant at the hospital following renal failure but did not survive surgery in November 1995. Six months later an inquest ruled Adam died from cerebral oedema – brain swelling – partly due to the onset of dilutional hyponatraemia, which occurs when there is a shortage of sodium in the bloodstream. Two expert anaesthetists told the coroner that the administration of an excess volume of fluids containing small amounts of sodium caused the hyponatraemia. But Dr Taylor resisted any criticism of his fluid management and refused to accept the condition had been caused by his administration of too much of the wrong type of fluid. In 2004 a UTV documentary When Hospitals Kill raised concerns about the treatment of a number of children, including Adam, and led to the launch of the Hyponatraemia Inquiry. The tribunal found Dr Taylor acted dishonestly on four occasions in his dealings with the the public inquiry, including failing to disclose to the inquiry a number of clinical errors he made and falsely claiming to detectives he spoke to Adam’s mother before surgery. Read full story Source: The Independent, 22 June 2022 -
News Article
Watchdog warns over medication risk to vulnerable
Patient Safety Learning posted a news article in News
Vulnerable patients cared for in secure mental health units across England could miss out on vital medications due to a shortage of learning disability nurses, the Healthcare Safety Investigation Branch (HSIB) has warned. The report into medication omissions in learning disability secure units across the country highlights problems with retaining learning disability nurses, with the number recruited each year matching those leaving. Figures quoted in the report suggest the number of learning disability nurses in the NHS nearly halved from 5,500 in 2016 to 3,000 in 2020. The HSIB launched a national investigation after being alerted to the case of Luke, who spent time in NHS secure learning disability units but was not administered prescribed medication for diabetes and high cholesterol on several occasions. At Luke’s facility, which included low and medium secure wards, HSIB investigators considered that the quality and style of care provided to patients had been directly impacted by a lack of nurses with required skill sets. Findings from HSIB’s wider national investigation link a shortfall of learning disability nurses to instances of patients missing their medication, with the report’s authors describing a “system in which medicines omissions were too common and prevention, identification and escalation processes were not robust”. Read full story (paywalled) Source: HSJ, 23 June 2022 -
News Article
Boots criticised over pill boxes for the elderly
Patient Safety Learning posted a news article in News
Some pharmacies run by the High Street chain Boots have been criticised for telling some patients on multiple drugs that they can no longer have blister pack boxes, known as dosette boxes or multi-compartment compliance aids (MCCAs). Weekly pill organisers can help users keep track of their daily medication and stay safe. Pharmacists put the tablets into individual boxes in the trays, each one indicating when they should be taken. The NHS says boxes are not always available for free on the NHS and they're not suitable for every type of medicine. Tracey Hobbs' mother, Pat Garner, lives at home with care visits. For several years, she has had her MCCAs provided by her local Boots pharmacy. She takes more than 15 pills each day. Tracey says she was phoned by Boots and told that from one month later her mother would receive all the drugs in the original packaging, rather than organised into morning and night doses for each day of the week. Tracey told the BBC: "I pointed out that the blister packs were the only way we could know she had taken her medication at the right time. Handing seven individual boxes with different instructions on each one was totally unworkable and - quite frankly - dangerous". A Boots spokesperson said: "The latest Royal Pharmaceutical Society guidance indicates that the use of multi-compartment compliance aids is not always the most appropriate option for patients that need support to take their medicines at the right dose and time." "Pharmacists are speaking with patients who we provide with MCCAs to discuss whether it is the right way to support them, depending on their individual circumstances and clinical needs." Prof Gill Livingston, an expert in elderly medicine at University College London, said she was concerned to hear that some patients and their families were being told the boxes were being scrapped. She said: "Blister packs enable people with mild dementia or some memory problems to take their own medication and remain independent. They can check that they have taken it and they know they have taken the right thing, as it is already sorted out. "Later on in dementia or with other disabilities, it enables paid carers and families to help them take their medication and remain in the community and remain as well as possible." Read full story Source: BBC News, 21 June 2022 -
Content ArticleStaying in hospital can be a frightening experience for people with diabetes. In 2017, an estimated 9,600 people required rescue treatment after falling into a coma following a severe hypoglycaemic attack in hospital and 2,200 people suffered from Diabetic Ketoacidosis (DKA) due to under treatment with insulin. This report by Diabetes UK outlines the patient safety issues and suggests the following measures are needed to make hospitals safer for people with diabetes: multidisciplinary diabetes inpatient teams in all hospitals better support in hospitals for people to take ownership of their diabetes better access to systems and technology more support to help hospitals learn from mistakes strong clinical leadership from diabetes inpatient teams knowledgeable healthcare professionals who understand diabetes.
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Content ArticleMedicines reconciliation is the process of accurately listing a person’s medicines. This could be when they're admitted into a service or when their treatment changes.
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News Article
‘It was horrific’: Women given saline instead of fentanyl, US lawsuit says
Patient Safety Learning posted a news article in News
When a couple decides to try to have a child by in vitro fertilisation, it’s often accompanied by anticipation, anxiety and worry about whether the egg and sperm will unite and produce a healthy baby. So when the procedure to retrieve eggs from a woman’s ovary turns out to be physically painful, it can create long-term emotional pain as well, according to a lawsuit and two women who underwent the procedure at the Yale University Reproductive Endocrinology and Infertility Clinic. They are among dozens of women and spouses who are suing Yale University, claiming the staff at the clinic should have known that, instead of receiving fentanyl to relieve pain during the procedure, they instead were being injected with saline — salt water. “The result was that dozens, perhaps hundreds, of women underwent the most painful fertility surgeries and procedures offered at the REI Clinic with little or no analgesia,” the lawsuit states. Angela Cortese, 33, of Vernon, who first had her eggs retrieved on Dec. 3, 2019, said the pain was “excruciating” as a nurse wiped tears from her eyes and Cortese tried “not to flinch every time they’re using this giant needle to retrieve the follicles.” “I want to say it was probably around 45 minutes that I was very much aware of what exactly was happening and feeling every pinch and prod,” she said. “And it doesn’t feel like somebody’s just pinching you. It feels like somebody’s stabbing you through your vagina. It was horrific.” Read full story Source: ctpost, 31 May 2022 -
Content ArticlePeople with living dementia or mild cognitive impairment and their family carers face challenges in managing medicines. This review, published in Age and Ageing, identifies interventions to improve medicine self-management for people with dementia and mild cognitive impairment and their family carers, and the core components of medicine self-management that they address.
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Content ArticleEffective Diabetes Education Now (EDEN) has created some resources for healthcare professionals to ensure vital information about insulin safety is communicated in way that supports the reduction of insulin errors. This webpage features infographic posters and a video about insulin safety.
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Content ArticleEZDrugID is a campaign to improve the distinctiveness of medication packaging set up by a group of healthcare workers. Inadequate standards around medication packaging mean that medications with very different actions are sometimes packaged in a very similar way causing "look-alike drugs”. This can lead to errors and serious harm to patients if the wrong drug is mistakenly used. The EZDrugID website contains information about their campaigns to maximise distinctiveness of different medications as well as a "lookalikes" gallery. See also: the hub's error traps gallery The medication safety area of the hub
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Content Article
In this blog Patient Safety Learning considers several key patient safety issues highlighted in a recent investigation by the Healthcare Safety Investigation Branch (HSIB) into unintentional overdose of morphine sulfate oral solution. We argue that in some areas, further action is required to prevent incidents of avoidable harm recurring. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
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Content ArticleDr Robert D. Glatter, medical advisor for Medscape Emergency Medicine, Dr Megan Ranney, professor of emergency medicine and the academic dean at Brown University School of Public Health and Dr Jane Barnsteiner, emeritus professor at the University of Pennsylvania School of Nursing, discuss the tragic case involving RaDonda Vaught, who was an ICU nurse who was recently convicted in Tennessee of criminally negligent homicide and gross neglect following a medical error due to administration of the wrong medication that led to a patient's death.
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Content ArticleChildren born to women who take valproate during pregnancy are at significant risk of birth defects and persistent developmental disorders. As such, it is vital that women and girls are dispensed valproate safely. The General Pharmaceutical Council is reminding all pharmacy professionals of what they must do to ensure women and girls receive the right information about valproate and the risk of birth defects. The update includes
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Content ArticlePresentation on the of theme of prevention of medication error from Philip A Routledge and James Coulson (All Wales Therapeutics and Toxicology Centre). Presentation available as slides a written transcript.
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Content Article
This visual guide by the UK Health Security Agency shows photographs of different vaccines used in the UK routine immunisation schedule and their packaging. It includes information on trade names and abbreviations, diseases each vaccine protects against and the age at which it should be administered. -
Content ArticleThe delivery of safe and effective healthcare to paediatric and neonatal patients presents unique challenges to the medication-use system. The diversity of patients within this population and the consequences of ontogeny on pharmacokinetics and pharmacodynamics directly impact the safe use of medications in children and increase the risk of adverse drug events. This review from Elkeshawi et al. will explore the medication-use system for hospitalised children and neonates, discuss vulnerabilities within this system, and provide examples of advancements made to improve the paediatric medication-use system.
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Content ArticleMedication safety events with the potential for patient harm do occur in healthcare settings. Pharmacists are regularly tasked with utilizing their medication knowledge to optimize the medication-use process and reduce the likelihood of error. To prepare for these responsibilities in professional practice, it is important to introduce patient safety principles during educational experiences. The Accreditation Council for Pharmacy Education (ACPE) and the American Society of Health-System Pharmacists (ASHP) have set forth accreditation standards focused on the management of medication-use processes to ensure these competencies during pharmacy didactic learning and postgraduate training. The experience described here provides perspective on educational and experiential opportunities across the continuum of pharmacy education, with a focus on a relationship between a college of pharmacy and healthcare system. Various activities, including discussions, medication event reviews, audits, and continuous quality improvement efforts, have provided the experiences to achieve standards for these pharmacy learners. These activities support a culture of safety from early training.
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Content ArticleAdverse drug reactions (known as ADRs) can occur both in the home, and within the healthcare setting, when combinations of medications produce unexpected side effects. Unfortunately this means that in the most serious cases fatalities can occur. However ADRe has helped all service users by addressing life-threatening problems, reducing pain or improving quality of life. With preventable ADRs responsible for 5-8% unplanned hospital admissions in the UK, and costing the NHS up to £2.5bn pa, it is crucial that healthcare organisations take advantage of tools which can help improve how medicines are managed. ADRe has been developed with the aid of nursing professionals to help nursing staff take a structured approach to the monitoring of medicines, identifying any ADRs service users may be experiencing, and then making changes to improve a patients' health and wellbeing.
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Content ArticlePotassium permanganate is routinely used in the NHS as a dilute solution to treat weeping and blistering skin conditions, such as acute weeping/infected eczema and leg ulcers. It is not licensed as a medicine. Supplied in concentrated forms, either as a ‘tablet’ or a solution, it requires dilution before it is used as a soak or in the bath. These concentrated forms resemble an oral tablet or juice drink and if ingested are highly toxic; causing rapid swelling and bleeding of the lips and tongue, gross oropharyngeal oedema, local tissue necrosis, stridor, and gastrointestinal ulceration. Ingestion can be fatal due to gastrointestinal haemorrhage, acute respiratory distress syndrome and/or multiorgan failure. Even dilute solutions can be toxic if swallowed. A Patient Safety Alert issued in 20142 highlighted incidents where patients had inadvertently ingested the concentrated form, and the risks in relation to terminology and presenting tablets or solution in receptacles that imply they are for oral ingestion, such as plastic cups or jugs. A review of the National Reporting and Learning System over a two-year period identified that incidents of ingestion are still occurring. One report described an older patient dying from aspiration pneumonia and extensive laryngeal swelling after ingesting potassium permanganate tablets left by her bedside. Review of the other 34 incidents identified key themes: healthcare staff administering potassium permanganate orally patients taking potassium permanganate orally at home, or when left on a bedside locker potassium permanganate incorrectly prescribed as oral medication. The British Association of Dermatologists (BAD) ‘Recommendations to minimise risk of harm from potassium permanganate soaks’ includes advice on formulary management, prescribing, dispensing, storage, preparation and use, and waste.
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News Article
Matching drugs to DNA is 'new era of medicine'
Patient Safety Learning posted a news article in News
We have the technology to start a new era in medicine by precisely matching drugs to people's genetic code, a major report says. Some drugs are completely ineffective or become deadly because of subtle differences in how our bodies function. The British Pharmacological Society and the Royal College of Physicians say a genetic test can predict how well drugs work in your body. The tests could be available on the NHS next year. It would have helped Jane Burns, from Liverpool, who lost two-thirds of her skin when she reacted badly to a new epilepsy drug. She was put on to carbamazepine when she was 19. Two weeks later, she developed a rash and her parents took her to A&E when she had a raging fever and began hallucinating. The skin damage started the next morning. Jane told the BBC: "I remember waking up and I was just covered in blisters, it was like something out of a horror film, it was like I'd been on fire." Jane's experience may sound rare, but Prof Mark Caulfield, the president-elect of the British Pharmacological Society, said "99.5% of us have at least one change in our genome that, if we come across the wrong medicine, it will either not work or it will actually cause harm." "We need to move away from 'one drug and one dose fits all' to a more personalised approach, where patients are given the right drug at the right dose to improve the effectiveness and safety of medicines," said Prof Sir Munir Pirmohamed, from the University of Liverpool. Read full story Source: BBC News, 29 March 2022 -
Content ArticleMedication errors are the most common adverse event in hospitals and have significant economic and health consequences. This white paper developed by the European Collaborative Action on Medication Errors and Traceability (ECAMET) Alliance collects the results of a pan-European survey on medication errors. It includes 25 reports comprising 13 country reports in English, eight translations in other languages, a private hospitals report, specialised oncology and ICU reports and one consolidated report. It makes several recommendations to reduce medication errors in hospitals and highlights the need to: establish a culture of safety. create strategies to improve communication. raise awareness and organise regular multi-disciplinary training meetings. systematically use accreditation/certification systems. introduce technological tools.
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Content Article
NHS Resolution report - Extravasation (30 November 2022)
Patient-Safety-Learning posted an article in Extravasation
Extravasation is the accidental leakage of any liquid from a vein into the surrounding tissues, which can cause serious harm to the patient. This report analyses the 467 claims relating to extravasation injuries received by NHS Resolution between 1 April 2010 and 1 December 2021. It includes information about specific injuries caused by extravasation, factors that led to injuries and specialities in which most injuries occurred. -
Content ArticleMedication errors can occur at any point in the system for prescribing, dispensing and administering drugs in the NHS – and can often be the result of human errors creeping in as burned out staff misread or miscalculate the amount needed. This article in the Health Services Journal examines how closed loop medication management systems can improve patient safety by ensuring patients are prescribed the right dosage of the right medications. The author speaks to Islam Elkonaissi, former lead pharmacist for cancer services in Cambridge, about the importance of well-planned implementation and bridging the gap between IT specialists and healthcare workers to make sure that potential for communication errors is minimised. They also discuss the value of the huge amounts of data AI systems can collect, which in turn make the systems more precise and accurate.
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Content ArticleThis document sets out the Northern Ireland Department of Health's ambitions to improve medication safety in Northern Ireland, in line with the World Health Organization's Third Global Patient Safety Challenge 'Medication without Harm'. It outlines the need for safer use of medicines in Northern Ireland and highlights four ways in which the Department for Health will address these challenges: Engagement with patients and the public Introducing new systems and practice Engagement and training of health and social care staff Reducing the burden of avoidable harm from high-risk medicines by building good practice in to the supply of all medications
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Content Article
In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the difficulties people experience in disposing of needles and injection devices safely at home. Variation in services across the UK can lead individuals to dispose of sharps incorrectly, posing a risk to refuse workers and the wider public.
