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Found 167 results
  1. Content Article
    Medicines 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.
  2. Content Article
    The 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.
  3. Content Article
    People 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.
  4. Content Article
    An increasing number of studies show that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety and reliability may be compromised. This article from Rozich et al. discusses how standardisation may help to increase uniformity of practice, increase safety, and possibly reduce costs. Also described is an effort made by Luther Midlefort, Mayo Health System, to reduce variation by creating a system-wide protocol for insulin use. After six weeks, Luther Midelfort achieved a great reduction in the number of hypoglycaemic events as a result of standardised practices.
  5. Content Article
    The World Health Organization Global Patient Safety Challenge, Medication Without Harm, aims to reduce serious, avoidable medication-related harm by 50% in 5 years, globally. Three areas have been identified for early priority action. This technical report addresses Medication Safety in Transitions of Care; why it is a priority, what has been done to address it to date and what needs to be done. 
  6. Content Article
    Presentation 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.
  7. Content Article
    Adverse 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.
  8. Content Article
    Effective 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.
  9. 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.
  10. Content Article
    This guide is designed to support healthcare providers when talking to patients about the use of of oxytocin to start or advance labour.
  11. Content Article
    Health systems currently present a great degree of complexity, which provides risks to patients related to healthcare, and the possibility of incidents with or without harm. Patient safety culture highlights the need to investigate, analyse, and mitigate incidents to reduce risks to the patient. Medication errors have a high potential to do harm in paediatric hospital routines and most of them are preventable. The objective of this study was to describe a severe drug-related adverse event and present the root cause analysis and implemented improvements.
  12. Content Article
    Duplicate 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.
  13. Content Article
    Medication errors present a major public health burden and there is a need to optimise risk minimisation and prevention of medication errors through the existing regulatory framework. The European Medicines Agency (EMA) in collaboration with the EU regulatory network was mandated to develop regulatory guidance for medication errors, taking into account the recommendations of a stakeholder workshop held in London in 2013. This guidance is intended to support the implementation of the new legal provisions regarding the reporting, evaluation and prevention of medication errors and is intended mainly for the pharmaceutical industry and national competent authorities. Healthcare professionals (HCP) are expected to consult national clinical guidance on reducing the risk of medication errors.
  14. Content Article
    This article discusses how medication safety can be improved in Canada. It explores the complexities of aging, what can go wrong with medication, 'Best Possible Medication Histories', the role of pharmacists and paramedics, engaging with patients and their families, and improving communication across the healthcare system.
  15. Content Article
    The 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. 
  16. 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.
  17. Content Article
    Medication errors are a common issue within the care home sector, impacting on the health and wellbeing of residents as well as creating challenges for care home staff and managers. This report addresses the issue of medication safety in care homes in England. Through intense engagement with a representative sample of care homes and stakeholders involving an electronic survey, workshops and conversations, Patient Safety Collaboratives have sought to understand the reasons for medication errors and how these could be avoided in the future.
  18. Content Article
    According 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.
  19. Content Article
    Specialist 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.
  20. Content Article
    In this article, Dr Diane Ashiru-Oredope and Eleanor Harvey from the UK Health Security Agency identify the risks of prescribing and dispensing oral antimicrobials and consider how pharmacy teams can minimise antimicrobial resistance.
  21. Content Article
    In the UK, over 26% of adults take prescription medications and in the US the figure is around 66%. But up to 50% of patients fail to take their medications as prescribed. As healthcare steadily pivots towards digital health, Dr. Bertalan Meskó and Dr. Pranavsingh Dhunno ask how new technologies can improve medication management. In this article for The Medical Futurist, they look at the importance of empowering patients to reduce the risk of medication errors. They highlight five medication management technologies that could help patients improve their own medication safety: Smart pill dispensers which deliver audible and visual cues to remind patients to take medications at the right time Medication reminder apps which help manage medication regimens and can sync the data with a caregiver or doctor Digital therapeutics which support patients to make treatment decisions Digital pills which integrate tracking technology into pills themselves Telemedical platforms that allow patients to request advice or raise concerns with their doctors.
  22. Content Article
    Sorrel King was a 32-year-old mother of four when her eighteen-month-old daughter, Josie, was horribly burned by water from a faulty water heater in the family's new Baltimore home. She was taken to Johns Hopkins--renowned as one of the best hospitals in the world--and Sorrel stayed in the hospital with Josie day-in and day-out until she had almost completely recovered. Just before her discharge, however, she was erroneously injected with methadone, and died soon after. Sorrel's account of her unlikely path from grieving parent to nationally renowned advocate is interwoven with descriptions of her and her family's slow but steady road to recovery, and ends with a deeply affecting description of a ski trip they took recently. The sun is shining, her children are healthy, and they are all profoundly happy--a condition that Sorrel has learned to appreciate all the more for Josie. The book ends with a resource guide for patients, their families, and healthcare providers; it includes information about how to best manage a hospital stay and how to handle a medical error if one does occur.
  23. Content Article
    The life expectancy of people with severe mental illness (SMI) is shorter than those without SMI, with multimorbidity and poorer physical health contributing to health inequality. Screening tools could potentially assist the optimisation of medicines to protect the physical health of people with SMI. The aim of this research from Carolan et al. was to design and validate a medicines optimisation tool (OPTIMISE) to help clinicians to optimise physical health in people with SMI.
  24. Content Article
    Medication errors are any Patient Safety Incidents (PSI) where there has been an error in the process of prescribing, preparing, dispensing, and administering, monitoring or providing advice on medicines. Medication errors can occur at many steps in patient care, from ordering the medication to the time when the patient is administered the drug. From April 1 2015 to 31 March 2020 NHS Resolution received 1,420 claims relating to errors in the medication process. Of those claims, 487 claims settled with damages paid, costing the NHS £35 million (excluding legal costs). NHS Resolution initial data for medication errors indicates that anticoagulants, opioids, antimicrobials, antidepressants, and anticonvulsants are the most common medications to be implicated in incidents.
  25. Content Article
    This year's World Patient Safety Day, due to take place on Saturday 17 September 2022, will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. In this blog for the hub, Laurence Goldberg, an independent pharmaceutical consultant, looks at how we can reduce drug administration errors by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient.
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