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Showing results for tags 'Adminstering medication'.
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Content Article
HSE Ireland - My Medicines List leaflet (January 2020)
Patient-Safety-Learning posted an article in Medication
This leaflet produced by the Irish Health Services Executive (HSE) provides a central place for patients to record information about their medications. It acts as a reference point for patients to use when discussing their medications with a healthcare professional and includes a reminder of the Know, Check, Ask campaign, aimed at reducing medication errors in the community. -
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Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. In recognition of this, in 2017 the World Health Organization (WHO) launched the Third WHO Global Patient Safety Challenge: Medication Without Harm, aimed at improving medication safety. This article provides information and resources related to the Challenge. -
Content ArticleEarlier this year in March, a nurse from Vanderbilt University, RaDonda Vaught, was found guilty of criminally negligent homicide and gross neglect of a patient. In 2017, Vaught gave 75-year-old Charlene Murphey the incorrect medication. Murphey died as a result. Charlene Murphey’s tragic death highlights the failures of healthcare organisations and their leadership to be trustworthy as well as a fractured and weakened accountability system for patient safety in the United States.
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Content ArticleOn the 21 July 2022 NHS Resolution’s Safety and Learning team, in partnership with the National Infusion and Vascular Access Society, hosted a virtual forum on extravasation injury claims. The intention of this event was to raise awareness of these injuries and help spread learning and process review across health providers.
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Content ArticleNHS Resolution received 172 claims relating to anti-infective medications between 1 April 2015 until 31 March 2020. Anti-infective medications include antibiotics, antivirals and antifungals. The analysis in this leaflet focuses on closed claims that have been settled with damages paid and concern an element of the prescribing process: prescribing, transcribing, dispensing, administering and monitoring. Claims concerning a failure to recognise that an anti-infective was indicated have not been included within the analysis.
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Laurence Goldberg, an independent pharmaceutical consultant, discusses the effectiveness and also the potential for harm of unit-dose medicines distribution. -
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WHO: World Patient Safety Day 2022
Patient Safety Learning posted an article in WHO
This year 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. This page links to resources to mark World Patient Safety Day from the official World Health Organization (WHO) website.- Posted
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Content ArticleThis blog on the NHS England website looks at how Written Medicine, a service that provides bilingual medication information, is helping to reduce healthcare inequalities and medical errors in London. Written Medicine’s software allows pharmacies and hospitals to translate and print medication information, instructions and warnings. Drawn from a dataset of 3,500 phrases, printed labels are available in fifteen different languages. The bilingual labels help patients take ownership of their treatment, giving them a better understanding of how to take their prescribed medication. The solution is helping to reduce errors, improve medication adherence and enhance patient safety and experience. The blog also looks at the experience of London North West University Healthcare NHS Trust (LNWH) using Written Medicine. A 2019 audit showed that the service was valued by patients and highly successful in increasing medication adherence through empowering patients.
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In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the safety issues faced by people with diabetes in hospital settings. Reflecting on feedback from Twitter users with diabetes, she looks at why so many people with diabetes fear having to stay in hospital, and asks what the NHS and its staff can do to make it a safer, less stressful environment. -
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Deprescribing. 'Do I really need this medicine?'
Patient Safety Learning posted an article in Medicine management
Overprescribing effects patient’s experience of, and engagement with, health and care services. It results in unnecessary costs and harm to patients. Watch this short video from Steve Turner. Reflection and key learning points based on UK laws and guidelines. -
Content ArticleIn 1999, the pivotal report “To Err is Human” by the Institute of Medicine led to sweeping changes in healthcare. This report outlined how blaming individuals does not change the underlying factors that contribute to medical errors. It also stated that blaming an individual does little to make the system safer – or prevent someone else from similar errors. It is unusual for a nurse to be charged criminally, when there is no intent to harm a patient. However, the recent trial in America of nurse RaDonda Vaught could set a precedent for future medical errors to be treated as criminal cases. The case may ensure that for every step that has been taken forward in patient safety, we have now taken two steps backwards. This article from Human Factors 101 looks at the case of RaDonda Vaught, the criminal trial and conviction, and discusses the impact this will have on healthcare.
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Content ArticleThe Australian Institute of Health Innovation conducts world-class research to catalyse health service and systems improvements in Australia and internationally. Its research generates highly practical evidence-based recommendations and information that health services can implement or use now. The Health Innovation Series supports clinicians, hospitals, policy makers and developers to apply this evidence to enhance the health system and services. The Health Innovation Series communicates research evidence in an easy-to-read, short format with clear recommendations, covering a wide range of topics.
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Content ArticleThe National Medication Safety Symposium was held in Sydney, Australia, in support of World Patient Safety Day. The presentations from the 2-day conference can be viewed on YouTube from link below.
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Content ArticleThe World Health Organisation's third World Patient Safety Day took place on 17 September. This year’s theme was medication safety. In this blog, Clare Wade, Assistant Director of Casework at the Parliamentary and Health Service Ombudsman (PHSO) discusses the impact of medication errors and gives examples of poor practice.
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Content ArticlePatient safety is often compromised by confusion over the graphic information on drugs packaging. Injectable medicines are particularly susceptible to medical error. This study gives design guidance to make such packs safer.
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Content ArticleMany seniors remain unaware that certain medications may be harmful, despite high rates of polypharmacy and inappropriate medication use among community-dwelling older adults. Patient education is an effective method for reducing the use of inappropriate medications. Increasing public awareness and engagement is essential for promoting shared decision-making to deprescribe. The Canadian Deprescribing Network was created to address the lack of a systematic pan-Canadian initiative to implement deprescribing among older Canadians. The Canadian Deprescribing Network deliberately included patient advocates in its organisation from the outset, in order to ensure a key strategic focus on public awareness and education. In this paper, Turner et al. present the processes and activities rolled out by the Canadian Deprescribing Network as a blueprint model for engaging the public on deprescribing.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report sets out a case where a medication error with warfarin contributed to the death of a 79-year-old man. The patient had suffered a fall at home and had been admitted to hospital. An error on his chart whilst he was on the ward led to him receiving four or five doses of warfarin, which he did not normally take, before the error was spotted by a ward-based clinical pharmacist. The patient developed internal bleeding and deteriorated (due to several health reasons) and died 21 days after his first admission. Research published this year suggests that medication errors may directly cause around 712 deaths per year and indirectly contribute to 1,708. The report highlights the growing ageing population and that pharmaceutical care of older people can be complex. They are often taking multiple medications and are at the greatest risk of harm due to medicine-related errors.
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Content ArticleThis document from the Patient Safety Authority outlines final recommendations to acute care facilities in the USA regarding patient weights. The Patient Safety Authority is responsible for submitting recommendations to the Department of Health (Department) in the US for changes in health care practices and procedures which may be instituted for the purpose of reducing the number and severity of serious events and incidents.
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Content ArticleThe United States is one of only three countries in the world that does not use the metric system. Yet, every single medication prescribed today is based on it. In addition to dosages based on the metric system, some doses are also very dependent on patient weight. These include blood thinners, certain antibiotics, chemotherapy agents, and many pediatric doses. The very young, very old, and people with certain medical conditions are at the highest risk of experiencing harm because their bodies are more sensitive to the effects of an error. Calculations made with incorrect weights can have devastating, if not fatal, consequences. Further reading Patient Safety Authority Department of Health: Final recommendation to ensure accurate patient weights
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Content ArticleNHS England and Improvement, in collaboration with the National Institute for Health and Care Excellence (NICE) and the Department of Health and Social Care (DHSC), has selected the first antimicrobial drugs to be purchased via the UK’s innovative ‘subscription-type’ payment model. Antimicrobial resistance (AMR) refers to the process by which microorganisms develop defences against antimicrobial drugs, enabling these microorganisms to adapt and become resistant to treatment. It’s a serious problem and has recently been identified as one of the World Health Organization’s top 13 global health challenges in the next decade. Without working antibiotics, routine surgery like caesarean sections or hip replacements will become too dangerous to perform, cancer chemotherapy will become prohibitively high-risk and certain infections will require long and complex treatment; or will no longer be treatable. Already, the microorganisms that cause many common diseases around the world – including tuberculosis, malaria, gonorrhoea, urinary tract infections and chest infections – can resist a wide range of antimicrobial medicines. Like all global challenges, leaders in the international community need to come forward and act on AMR, and the UK – with the NHS as the world’s largest single public health system – is taking the initiative. NHS England and Improvement project leads, Mark Perkins and David Glover, discuss this important step in tackling AMR.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals. Smart infusion pumps are the latest generation of programmable devices that administer medication. They are seen as a way of improving safety as the smart functionality aims to prevent underdoses or overdoses – they are equipped with features such as alerts or alarms to help detect problems. The investigation was launched after one NHS Trust recorded three incidents where a smart infusion pump delivered an overdose of fentanyl, a powerful pain medication. The patients weren’t harmed as it was swiftly picked up, however it emphasised the new risks that come with introducing new technology and the potential for serious medication errors. The investigation focused on the barriers to implementing the technology effectively across the NHS, rather than on the technology itself.
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Content ArticleAs prescription numbers continue to increase, it is necessary to understand the dispensing errors that can occur and how they may happen. This article is the first of two articles from Phipps et al. on dispensing errors and risk. Reducing risk and managing dispensing errors will build on the ideas proposed in this article.
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Content ArticlePharmacy teams should understand how to minimise the risk and likelihood of dispensing errors, including methods that can be used to evaluate existing processes, as well as how to deal with errors if they happen. This article from Phipps et al., in the Pharmaceutical Journal, builds upon the ideas proposed in ‘Understanding dispensing errors and risk’, and also proposes strategies and methods that should be considered for use in the pharmacy to manage the risk of dispensing errors.
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Content ArticleThe Comprehensive Unit-based Safety Program (CUSP) aims to improve the culture of safety while providing frontline caregivers with the tools and support that they need to identify and tackle the hazards that threaten their patients at the unit or clinic level. Developed by Johns Hopkins safety and quality researchers, the five-step programme has been used to target a wide range of hazards, including patient falls, hospital-acquired infections, medication administration errors, specimen labeling errors and teamwork and communication breakdowns. Notably, CUSP has been used in national and international quality improvement projects that have drastically reduced hospital-acquired infections. Whether your hospital has participated in such projects or is seeking to adopt CUSP, the Armstrong Institute provides resources to help you run a successful programme.
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Content ArticleThe Medication Errors Group was established in 2017 under the leadership of Dr Brian Edwards and Professor Ian Wong.. Ensuring the safe and effective use of healthcare products is a key objective for those who work in pharmacovigilance, as well as all other stakeholders, including patients and caregivers. One key element of that is working to reduce and mitigate medication errors and other irrational use of drugs. The mission of the Medication Errors Group is To provide an opportunity for International Society of Pharmacovigilance (ISoP) members, and like-minded collaborators, to network globally in a professional and neutral environment, to share evidence and solutions that can ideally eliminate and/or at least reduce the number and severity of medication errors. This will enable continuous improvement in the use of medicines whilst supporting the interests of patients and their families, and healthcare professionals.
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