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Showing results for tags 'Adminstering medication'.
Found 167 results
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News ArticleThe toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, a new report warns today. The Healthcare and Safety Investigation Branch (HSIB) report focuses on propranolol, a cardiac drug that is now predominately used to treat migraine and anxiety symptoms. It is highly toxic when taken in large quantities and patients deteriorate quickly, making it difficult to treat. The investigation highlighted that these risks aren’t known widely enough by medical staff across the health service, whether issuing prescriptions to at risk patients, responding to overdose calls or carrying out emergency treatment. Dr Stephen Drage, ICU consultant and HSIB’s Director of Investigations, said: “Propranolol is a powerful and safe drug, benefitting patients across the country. However, what our investigation has highlighted is just how potent it can be in overdose. This safety risk spans every area of healthcare – from the GPs that initially prescribe the drug, to ambulance staff who respond to those urgent calls and the clinicians that administer emergency treatment." The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose. Read full story Source: HSIB, 6 February 2020
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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 ArticleThis National Patient Safety Agency (NPSA) booklet presents information concerning how better design can be used to make the dispensing process safer in community pharmacies, dispensing doctor practices and hospital pharmacies. There are a number of new factors that will impact on the dispensing process, such as: electronic prescription services; auto-id and automation technologies; more responsibilities for pharmacy technicians; and enhanced pharmacy services. These factors have been incorporated into these safer design recommendations Organisations, managers and healthcare workers involved in dispensing medicines should use this booklet as a resource to help introduce new initiatives to further minimise harms from medicines.
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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 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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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 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 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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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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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 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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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. -
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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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 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 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 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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NHS England: Support for prescribers
Patient Safety Learning posted an article in Medication administration
NHS England has commissioned the Specialist Pharmacy Service to provide prescribers with all the support they need to: Stop prescribing medicines which are not clinically-effective or cost-effective Provide clear information to patients to help them make meaningful choices and decisions about their treatment Help people to get the benefits they want from their prescribed medicines Encourage people to ‘self-care’ and choose not to take a medicine if they don’t really need one Take positive action to reduce waste so we stop throwing away so many medicines. -
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 ArticleMedication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. The Pennsylvania Patient Safety Reporting System (PA-PSRS) was queried and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020.
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Uppsala Monitoring Centre: VigiBase
Patient Safety Learning posted an article in Adverse interactions
VigiBase is the Uppsala Monitoring Centre (UMC)’s starting-point for the journey from data to wisdom about safer use of medicines and wise therapeutic decisions in clinical practice. It is the driving-force at the heart of the work of UMC and the WHO Programme. The purpose is to ensure that early signs of previously unknown medicines-related safety problems are identified as rapidly as possible. VigiBase is the unique WHO global database of individual case safety reports (ICSRs). It is the largest database of its kind in the world, with over 20 million reports of suspected adverse effects of medicines, submitted, since 1968, by member countries of the WHO Programme for International Drug Monitoring. It is continuously updated with incoming reports.
