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Showing results for tags 'Adminstering medication'.
Found 167 results
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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 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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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 objective of the national Medicines Safety Improvement Programme is to help patients get the maximum benefit from their medicines and reduce waste with an overarching aim to reduce medication related harm in health and social care, focusing on high risk drugs, situations and vulnerable patients. Each area of work in this programme intends to make medicines safety part of routine practice, ensure medicines use is as safe as possible and understand the patients’ experience. The national Medicines Safety Improvement Programme (MedSIP) is led by NHS England and Improvement’s patient safety team. The programme is delivered by the West of England Patient Safety Collaborative. Learn more about the West of England's MedSIP.
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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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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 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 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 study in BMC Medicine aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings. It is the largest meta-analysis to assess preventable medication harm to date. The authors found that one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Their results support the World Health Organization’s priority of detecting and mitigating medication-related harm and highlight other potential intervention targets that should be a priority research focus.
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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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EventThis Westminster conference will discuss the strategic priorities for tackling overprescribing in the NHS. It follows NHS England’s overprescribing review and subsequent Good for You, Good for Us, Good for Everybody action plan. Delegates will discuss what would be needed if the plan’s aims for systemic and cultural change are to be achieved, and priorities for the proposed Clinical Director for Prescribing. It will be an opportunity to discuss the future of medicines optimisation, opportunities for social prescribing, and measures to enable consistent delivery across the whole population and to expand the workforce to deliver non-medical treatments where possible. Key areas for discussion include: culture change - including development of leadership and accountability around overprescribing at national and ICS level - key issues for the Clinical Director for Prescribing systemic change - the role of social prescribing - strategic priorities for medicines optimisation - practicalities of scaling up: funding, staffing, training, and engagement with patients patient-centred care - practical steps - involving patients with managing long-term conditions - building support and frameworks required for development research - sharing best practice and guidance - building the evidence base - developing understanding of the groups most impacted digital - the role of digital transformation in supporting patient-centred care and the ability to make more informed care decisions - improvements to patient records pharma - system-wide collaboration and industry transparency. Agenda Register
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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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News ArticleNHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients. The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk. The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years. HSIB launched a national investigation into the problem of misplaced nasogastric (NG) tubes after a 26-year-old man had 1,450ml of liquid feed fed into his lungs in December 2018 after a bike accident. The patient recovered but the error was not spotted, even after an X-ray. Read full story Source: The Independent, 17 December 2020
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EventDr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a group of experts, including pharmacists, anesthesiologists, respiratory therapists, family members, and nursing leaders, to explore the patient safety priorities of sedation, opioid therapy and respiratory depression. The group will discuss frequently encountered safety issues, explore organisational processes to reduce sedation safety events, and assess the role patients and family members can play in reducing harm. Register
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Content ArticlePatients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. This systematic review in BMJ Quality & Safety aimed to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.
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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 Article
In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting. As its ‘reference case’, the investigation uses the experience of Kathleen, a 73 year old woman with type 2 diabetes who received two recognised overdoses of insulin while she was in hospital. On both occasions she became hypoglycaemic, received medical treatment, and recovered. Patient Safety Learning has published a blog reflecting on some of the key patient safety issues highlighted in this report.
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Content Article
Extravasation: a patient safety priority
Patient Safety Learning posted an article in Extravasation
Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue causing trauma. This leaflet describes the risks posed by extravasation to patients, the extent of the problem in the NHS and what is currently being done to reduce the risk of avoidable harm. The leaflet sets out the action to prevent, recognise, treat and report extravasation which is urgently needed. It emphasises the importance of all suspected extravasation injuries being reported and investigated, with reviews undertaken to learn and take action to prevent harm to future patients. -
Content ArticleMedicines play a crucial role in maintaining health, preventing illness, managing chronic conditions and curing disease. However, there is a growing body of evidence that shows us that there is an urgent need to get the fundamentals of medicines use right. Medicines use today is too often sub-optimal and we need a step change in the way that all healthcare professionals support patients to get the best possible outcomes from their medicines. Medicines optimisation represents that step change. It is a patient-focused approach to getting the best from investment in and use of medicines that requires a holistic approach, an enhanced level of patient centred professionalism, and partnership between clinical professionals and a patient. Medicines optimisation is about ensuring that the right patients get the right choice of medicine, at the right time.
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