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Showing results for tags 'Medication - related'.
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Content ArticleUsing a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. Patel et al., following a near-miss and subsequent educational and training efforts at their institution, they conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. They found only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.
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- Human factors
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Content ArticleArterial lines are routinely fitted for severely ill patients in critical care and are flushed with a solution to maintain patency, and ensure that blood does not clot in the line. Saline is recommended as the flush solution for arterial lines. There are several examples of glucose solutions being inadvertently and incorrectly used to flush arterial lines. This has lead to inaccuracies in blood glucose measurements, which resulted in unnecessary administration of insulin and subsequent cases of hypoglycaemia, some of which have been fatal.
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- Medication - related
- Patient safety incident
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Content ArticleThere are an estimated 200,000 severe adverse drug errors (ADRs) in Canada each year, though it is estimated that 95% of ADRs are not reported. They cost the Canadian healthcare system between $13.7 and $17.7 billion each year and kill up to 22,000 Canadians each year. Over 5,000 of these are Canadian children. ADR Canada is working to prevent this. This article explains the role of genomics in the solution to adverse drug reactions.
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- Patient
- Medication
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Safe practices for drug allergies using CDS and health IT (2019)
Claire Cox posted an article in Allergies
The Partnership for Health IT Patient Safety, a national collaborative convened by ECRI Institute, has released a new report on drug allergy interactions and how clinical decision support (CDS) and health information technology (IT) can be used to improve safety. Drug allergy alerts, a feature of clinical decision support (CDS), incorporated within the electronic health record (EHR), act as a safeguard against prescribing or dispensing a medication to which a patient has a documented allergy that could cause an adverse event for a patient. Drug allergy interactions are an important patient safety concern. Inadequate communication and display of drug allergy interaction information may result in incorrect treatment, delay care, or result in additional or prolonged care for a patient.- Posted
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Content ArticleMedicines reconciliation and medication reviews play an integral part in medicine optimisation. 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. It involves recording a current list of medicines, including over-the-counter and complementary medicines. Then, the list is compared with the medicines the person is actually using. It involves recognising and resolving any discrepancies and documenting any changes. The medicines reconciliation process will vary depending on the care setting that the person has moved into (or from). Trained and competent staff should carry out the medicines reconciliation. They should consult with a health professional. Ideally, this should be the person’s GP, nurse or pharmacist.
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- Pharmacist
- Post-discharge support
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Antibiotic awareness: quizzes and crosswords (updated 2017)
Claire Cox posted an article in Medicine management
The Antibiotic Guardian has produced a range of quizzes and crosswords about antibiotic resistance for the public, healthcare prescribers and pharmacists.- Posted
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Content ArticleAntibiotic resistance is an increasingly serious threat to global health and human development. It is rising to dangerously high levels in all parts of the world, compromising our ability to treat infectious diseases and putting people everywhere at risk.
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- Prescribing
- Skills gap
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PHE: Become an antibiotic guardian
Claire Cox posted an article in Medicine management
The Antibiotic Guardian campaign is led by Public Health England (PHE) in collaboration with the Devolved Administrations (Scotland, Wales and Northern Ireland); the Department for Environment Food and Rural Affairs (DEFRA) and professional bodies/ organisations towards the ‘One Health’ initiative. Antibiotic resistance is one of the biggest threats facing us today. Without effective antibiotics many routine treatments will become increasingly dangerous. Setting broken bones, basic operations, even chemotherapy and animal health all rely on access to antibiotics that work. To slow resistance we need to cut the unnecessary use of antibiotics. The Antibiotic Guardian invite the public, students and educators, farmers, the veterinary and medical communities and professional organisations, to become Antibiotic Guardians.- Posted
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Patient Safety Journal
Claire Cox posted an article in Suggest a useful website
The latest issue of the Patient Safety Journal is now out. US patient safety journal brought to you by the Patient Safety Authority, an independent agency of the Commonwealth of Pennsylvania. Each issue publishes original, peer-reviewed research and data analyses and also gives patients a voice. It's mission is to give clinicians, administrators and patients the information they need to prevent harm and improve safety.- Posted
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- protocols and procedures
- Process redesign
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Bottle of Lies by Katherine Eban
Patient Safety Learning posted an article in Recommended books and literature
The troubles of Indian pharma companies abroad raise questions about the domestic drug regulator. Although Bottle of Lies, a book about the quality problems plaguing generic drugs, focuses on medicines intended for American consumers, the real and continuing victims of the failings described in the book are consumers in developing countries, including Indians. In May 2013, soon after the erstwhile Ranbaxy Laboratories admitted in an American court to selling adulterated drugs, journalist Katherine Eban published a gripping 10,000-word account of the saga in Fortune magazine. But the story left Eban wondering if Ranbaxy was an isolated case. Could there be more rotten eggs, she asked, given the United States Food & Drugs Administration’s (FDA) lax policing of overseas manufacturers? Bottle of Lies is the result of the multi-year investigation that followed.- Posted
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- Medication
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Content ArticleFrimley Health NHS Foundation Trust have devised a patient leaflet to help patients play a role in their safety while at the hospital.
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- Patient
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Content ArticleThe Black Country Partnership NHS Foundation Trust's medication error policy and pathway describes the procedure that must be followed when a medication error occurs.
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PRSB podcast: Making medications safer
Patient Safety Learning posted an article in Medication including labelling
The Professional Record Standards Body (PRSB) speaks to Ann Slee, Associate CCIO, Medicines at NHS England, in this podcast on making medications safer.- Posted
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- Medication
- Medication - related
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ECRI - Top 10 Patient Safety Concerns 2020
Claire Cox posted an article in International patient safety
ECRI Institute's Top 10 Patient Safety Concerns for 2020 features new topics, with an emphasis on concerns that have the biggest potential impact on patient health across all care settings. However, the number one topic on this year's list is one revisited from 2019: missed and delayed diagnoses.- Posted
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- Obstetrics and gynaecology/ Maternity
- Decision making
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Content ArticleUniversity Hospitals of Leicester NHS Trust (UHL), IBSL (UK) Limited and Santa Lucia Pharma Apps SrL (SLPA), with support from EMAHSN and Loughborough University, have deployed a unit dose closed loop medicines management solution in four wards at UHL and undertaken an 18-month evaluation of the project (OptiMed-ID) in preparation for a Trust-wide rollout.
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Content ArticleCraig Bradley is Product & Business Lead (Associate Director) at Shire Pharmaceuticals and Chair of the Pharmaceutical Marketing Society. Here he talks about the importance of patient engagement within the pharmaceutical industry.
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- Patient
- Pharmacist
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