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Showing results for tags 'Adminstering medication'.
Found 168 results
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Content Article
Prevention of Future Deaths report – Van Tuyen (22 February 2022)
Mark Hughes posted an article in Coroner reports
Van Thai Tuyen was admitted to the Royal London Hospital on 1 August 2021 for treatment of a stroke. A nasogastric tube was inserted to administer medication and food, due to Mr Tuyen being assessed as having an unsafe swallow. Despite an x-ray showing that the nasogastric tube had been misplaced into his right lung the tube was used to administer approximately 300ml of liquid feed. This caused the cavitating necrotising pneumonia from which he died.- Posted
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Content ArticleUnsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. The World Health Organization (WHO) has launched the Third WHO Global Patient Safety Challenge: Medication Without Harm to improve medication safety. Considering the huge burden of medication-related harm, Medication Safety has also been selected as theme for World Patient Safety Day 2022. WHO is launching a series of webinars to introduce the strategic framework for implementation of the Challenge, technical strategies, tools and provide technical support to countries for reducing medication-related harm. The webinars will share country and patient experiences in implementing the Challenge. These presentations from the opening webinar sets out the urgency to address the challenge, the strategic framework and progress to date.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explores the prescription of oral paracetamol in adult inpatients who, on admission to hospital, have low bodyweight (less than 50kg). Paracetamol is a common painkiller often used as first-line management for mild to moderate pain. Although it is safe if taken at the right dose, paracetamol in large amounts is toxic to the liver and therefore the maximum dose must never be exceeded. As its 'reference case', the investigation used the case of Dora, an 83-year-old woman who weighed less than 50kg on admission and lost further weight in hospital. While in hospital, Dora was prescribed oral paracetamol 1g four times a day and towards the end of her admission, she developed multiorgan failure due to sepsis and was diagnosed with paracetamol-induced liver toxicity.
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Content ArticleThe US Institute for Safe Medication Practices (ISMP) list of error-prone abbreviations, symbols, and dose designations contains abbreviations, symbols, and dose designations which have been reported through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been misinterpreted and involved in harmful or potentially harmful medication errors. These abbreviations, symbols, and dose designations should NEVER be used when communicating medical information verbally, electronically, and/or in handwritten applications. This includes internal communications; verbal, handwritten, or electronic prescriptions; handwritten and computer-generated medication labels; drug storage bin labels; medication administration records; and screens associated with pharmacy and prescriber computer order entry systems, automated dispensing cabinets, smart infusion pumps, and other medication-related technologies.
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Content ArticleOn the 15 May 2020, John Skinner was admitted to Watford Hospltal suffering from a tonic clonlc seizure. He had a background of cannabis usage and a subdural empyema in 2020 that had left him with epilepsy. On arrival at hospital he again had another tonic clonlc seizure and focal seizures. The Junior doctor Instructed to administer the drug sought advice from a more senior doctor as to the dose to be administered. As a result of a failure In verbal communication between the doctors, aggravated as both were masked, a dose of 15 mg/kg was heard as 50 mg/kg and an overdose was administered. He was given 3600 mg of phenytoln. He arrested within 16 minutes and died and could not be revived.
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Content ArticleThis report describes an adverse incident at Queen's Medical Centre in Nottingham in 2001, when a male patient being treated for leukaemia died after being mistakenly given the chemotherapy drug Vincristine intrathecally (into the spine). Vincristine should be administered intravenously, and accidental intrathecal administration of Vincristine is almost always fatal.
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Content ArticleThis training video illustrates guidance from the Department of Health on safe administration of intrathecal medications.
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Content ArticleThis white paper documents a roundtable discussion held at the International Forum on Quality and Safety in Health Care in Europe 2021. Participants discussed how smart medication management can be improved to optimise healthcare quality and efficiency. The meeting was chaired by Yu-Chuan (Jack) Li, a researcher of artificial intelligence (AI) in medicine and medical informatics, and editor-in-chief of BMJ Health and Care Informatics.
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Content ArticleMedication errors are any Patient Safety Incidents (PSI) where there has been an error in the process of prescribing, preparing, dispensing, administering and monitoring or providing advice on medicines. From 1 April 2015 until 31 March 2020 NHS Resolution received 1420 claims relating to medication errors. This leaflet from NHS Resolution analyses closed claims that have been settled with damages paid and concern an element of the medication process: prescribing, transcribing, dispensing, administering and monitoring.
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Content Article
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In this blog, Lotty Tizzard, Patient Safety Learning's Content and Engagement Manager, looks at some of the patient and staff safety issues surrounding insulin delivery. These issues have been identified by a new working group set up by the Safer Healthcare and Biosafety Network (SHBN), and she also highlights potential solutions the group will explore. The SHBN is an independent forum focused on improving healthcare worker and patient safety. It has established a working group on improving injection technique and delivering dual safety in diabetes care. The working group consists of clinicians, policy-makers, charities, manufacturers and patients who are concerned about high numbers of preventable safety incidents related to diabetes treatment. -
Content ArticleAn examination of how humans interact with their environments and each other led this team to question one of its long-standing medication safety practices and change how they work.
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Content ArticleThis article looks at an incident of unsafe prescribing of haloperidol that resulted in overdose and the death of an elderly patient.
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Content ArticleThis report highlights the risk of patient overdose when converting tacrolimus (a medicine used following organ transplantation) from an oral to intravenous route.
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Content Article
NHS England: Ceftazidime as a 24-hour infusion
Becky T posted an article in Medication administration
Through its core work to review patients safety events, recorded on national systems such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified a patient safety issue where the antibiotic ceftazidime was infused over 24 hours. -
Content ArticleThis study, published in JAMA Network Open, looks at whether publicly reported feedback was associated with hospital improvement in an evaluation of medication-related safety performance. The results indicate that publicly reported feedback was associated with quality improvement, and the authors suggest that targeted measurement and reporting of process quality may be effective in encouraging improvement in specific areas.
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Content ArticleThis study in Anaesthesia reviewed accidental spinal administration of tranexamic acid. The review identified 20 cases of accidental administration resulting in life-threatening neurological or cardiac complications and 10 patient deaths. These cases were analysed using a Human Factors Analysis System Classification model to identify contributing factors. Ampoule error was the cause in 20 incidents, and all were classified as skills-based errors. Organisational policy, storage of medication and preparation for anaesthesia were all identified as contributing factors. The authors concluded that all of these events could have been avoided if four published recommendations for the prevention of spinal medication administration were implemented.
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Content ArticleThe risk of medication errors with infusion pumps is well established, yet a better under-standing is needed of the scenarios and factors associated with the errors. This study from the Patient Safety Authority explored the frequency of medication errors with infusion pumps, based on events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) during calendar year 2018.
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Content ArticleAn examination of how humans interact with their environments and each other led a team at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, USA, to question one of its long-standing medication safety practices and change how they work.
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Content ArticleThe government commissioned Dr Keith Ridge, Chief Pharmaceutical Officer for England, to lead a review into the use of medication and overprescribing.
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Content ArticleThis study, published in JAMA Network Open, looks at the effectiveness of using an evidence-based mobile app to reduce the occurrence of medication errors, compared with conventional preparation methods during simulated paediatric out-of-hospital cardiac arrest scenarios. Its results indicated a decreased rate of medication errors through use of a mobile app, suggesting this could have the potential to improve medication safety and change practices in paediatric emergency medicine.
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Content ArticleIn this article in the Pharmaceutical Journal, Carolyn Wickware asks if liquid morphine should be reclassified. She cites research that Oramorph or oral morphine sulphate solution was directly linked to the cause of death in 13 reports since 2013.
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Content ArticlePharmacovigilance is the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other medicine/vaccine related problem. This article, published in the journal Drug Safety, outlines how the Egypt Chapter of the International Society of Pharmacovigilance (ISoP) approached raising awareness of the importance of pharmacovigilance and reporting adverse drug reactions during MedSafetyWeek 2020.
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Content ArticleClinical pharmacists reduce medication errors and optimise the use of medication in critically ill patients, although actual staffing level and deployment of UK pharmacists is unknown. The primary aim of this study was to investigate the UK deployment of the clinical pharmacy workforce in critical care and compare this with published standards. The authors conclude that investment in pharmacy services is required to improve access to clinical pharmacy expertise at weekends, on MDT ward rounds and for other critical care activities.
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Content ArticleThis webinar is part of Global Patient Safety Webinar Series 2021 and focuses on the third WHO Global Patient Safety Challenge: Medication Without Harm. The webinar presents on overview of the Challenge, technical tools and resources to support its implementation and different approaches to implement the challenge at national, subnational, facility and community levels. A recording of the webinar is available below.
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Content ArticleThis is an analysis of medication errors from January 2018 to December 2019 reported at a university teaching hospital in Riyadh, Saudi Arabia, aimed at identifying whether medication errors are significantly different between day shifts, night shifts, during weekdays and weekends. It found that there was a statistically significant difference between medication errors and day of the week, with a higher number of medication errors happening at the weekend. It also found that during weekends, medication errors were more likely to occur at the night shift compared to the day shift. The authors suggest that timing of medication errors incidence is an important factor to be considered for improving the medication use process and improving patient safety.
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