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Found 1,118 results
  1. Content Article
    This video is based on research interviews with acute medical patients and examines how staff and patients in hospital can create safe care together. It includes quotes from real-life patient experiences and highlights the importance of listening to and reassuring patients, and involving them in their care.
  2. 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.
  3. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  Dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause. We have picked nine resources and reflections about keeping people with dementia safe in health and care settings, and when considering medication choices.
  4. Content Article
    In a UK-first report launched in the House of Commons, leading figures from charity, healthcare, industry, law and academia have outlined a collaborative vision for UK leadership to improve maternal health. The Healthy Mum, Healthy Baby, Healthy Future: The Case for UK Leadership in the Development of Safe, Effective and Accessible Medicines for Use in Pregnancy report proposes a clear roadmap to improve the lives of millions of people, not just for women while they are pregnant, but for future generations. Over the past year, a Birmingham Health Partners led Policy Commission – co-chaired by Baroness Manningham-Buller, Co-president of Chatham House and Professor Peter Brocklehurst, University of Birmingham – has heard from key stakeholders on how best to develop safe, effective and accessible medicines for use in pregnancy. Compelling evidence gathered throughout the process has informed eight critical recommendations which, if implemented by government, will successfully prevent needless deaths and find new therapeutics to treat life-threatening conditions affecting mothers and their babies.
  5. Content Article
    The Reducing Restrictive Practice Collaborative (RRP) aimed to reduce restrictive practice by one third in participating wards, measuring the following practices: Restraint – to prevent, restrict or subdue movement of the body, or part of the body of another person Seclusion – confinement in a room or physical space Rapid tranquillisation – use of sedative medication by injection. This webpage contains a number of resources related to the work of the collaborative, including a resource booklet outlining learning about running successful quality improvement projects.
  6. 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.
  7. 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.
  8. Content Article
    The Canadian Institute of Safe Medication Practice's bulletins. Learn about strategies to mitigate harm and to prevent medication errors based on analyses of medication incident reports from Canadian healthcare providers, facilities, pharmacies, organisations and consumers.
  9. Content Article
    The Institute for Safe Medication Practices Canada is a trusted partner in strengthening medication safety through learning, sharing, and acting to improve healthcare. A team of experts analyse reports of medication errors from across the country and provide resources, education, and consulting services to improve medication safety.
  10. Content Article
    Polypharmacy refers to the prescription of many medicines to one patient. As more people live longer with multiple long-term conditions, the number of medicines they take often increases. This can have a significant burden on the person managing and trying to adhere to multiple medicines regimes, and can also be harmful. The Academic Health Science Networks (AHSN) Network's Polypharmacy Programme aims to support healthcare professionals to identify patients at potential risk from polypharmacy, and to support better conversations about medicines. Based on the recommendations of the National Overprescribing Review (NOR) published in September 2021, the programme aims to achieve the following outcomes: A national network of Polypharmacy Communities of Practice, all working to address the system-wide challenges of problematic polypharmacy in their geographies. Routine use of the NHSBSA Polypharmacy Prescribing Comparators to identify and prioritise patients for a shared decision-making Structured Medication Review. Increased confidence amongst the primary care prescribing workforce to safely stop medicines identified to be inappropriate or unnecessary. A change in patient expectations – to anticipate having a shared decision-making conversation about their medicines regularly, especially as they get older. A contribution to the evidence base around how to help patients to feel more empowered to open up about their medicines issues. A contribution to the evidence base around how to tackle problematic polypharmacy.
  11. Content Article
    In this article for The Guardian, journalist Sirin Kale speaks to Janet Williams about the impact the epilepsy drug sodium valproate has had on her family. Janet took the medication to treat her epilepsy throughout her two pregnancies in 1989 and 1991, but had never been warned about the potential risks to her babies. Foetal valproate syndrome can cause spina bifida, congenital heart defects and developmental delays and is believed to have affected around 20,000 children in the UK. Both of Janet's sons were affected by the medication and require full time care as a result. Janet describes how being told about the risks would have enabled her to make an informed decision about whether to have children, and how her experience led her to help set up In-FACT (the Independent Fetal Anti Convulsant Trust) in 2012.
  12. 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.
  13. Content Article
    The opioid epidemic is a major public health concern in the US—according to the Center for Disease Control and Prevention (CDC), 70,630 people died from drug overdoses and 10.1 million people misused opioid prescriptions in 2019 alone. There are also an estimated 180,000 serious opioid-related adverse events in inpatient settings recorded annually. This blog by Dr Diane Perez, advisory board member at the Patient Safety Movement Foundation, looks at how patients and their families can get involved in solving the opioid epidemic. Opioids are potent pain relievers so it is critical that anyone that has a prescription be properly informed about the potential risks–both in and out of the hospital setting.
  14. Content Article
    This National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report reviews the quality of care of patients aged 16 and over who had a pulmonary embolism (PE), The study aimed to highlight areas where care could be improved in patients with a new diagnosis of acute PE. A retrospective case note and questionnaire review was undertaken in 526 patients aged 16 and over who had a PE, and who either presented to hospital or developed a PE whilst an inpatient for another condition. You can view and download the following documents: Full report Summary report Summary sheet Recommendation checklist Infographic Slide set Commissioners' guide Fishbone diagram Audit toolkit YouTube video: Know the Score
  15. Content Article
    Recognising the scale of avoidable harm linked with unsafe medication practices and medication errors, WHO launched its third Global Patient Safety Challenge: Medication Without Harm in March 2017, with the goal of reducing severe, avoidable medication-related harm by 50% over the next five years, globally. This report, 'Medication safety in high-risk situations', outlines the problem, current situation and key strategies to reduce medication-related harm in high-risk situation.
  16. 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.
  17. 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.
  18. Content Article
    Oliver Pittock, managing director of pharmaceutical packaging supplier, Valley Northern, examines the areas of pharmaceutical packaging that require special attention, and how it can contribute towards a future of safer medication. Related content the hub's medication error traps gallery
  19. Content Article
    A blog from the Patients Association for World Patient Safety Day on why patient partnership is key to the safe prescribing, supply and taking of medicines. "Being prescribed medication is one of the most common interactions between patient and healthcare professional: this World Patient Safety, let’s ensure all medicine prescribed today is done so following a discussion of its benefits and risks and with the patient’s full participation."
  20. Content Article
    To mark World Patient Safety Day (WPSD) 2022 and in support of WHO's 5 moments for medication safety, the International Alliance of Patients' Organization (IAPO) has launched the "Humour me into medication safety" cartoons highlighting the 5 moments for medication safety - a patient engagement tool focusing on the key moments where action by the patient or caregiver can reduce the risk of harm associated with the use of medications. It aims to engage and empower patients to be involved in their own care through collaboration with health professionals.
  21. Content Article
    In this blog, Patient Safety Learning marks World Patient Safety Day 2022. It sets out the scale of avoidable harm in health and social care, the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, medication safety.
  22. Content Article
    After more than a decade and half of trying – unsuccessfully – to deal with her fibromyalgia through opioids, Louise finally decided that one way or another, she was going to have to manage her pain another way … In Louise’s words: “I got my life back – I’m living proof that there really is life after opioids!”
  23. 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. 
  24. Content Article
    Too often in health and social care poor medication practices and inadequate system infrastructure result in patient harm, with as many as 1 in 10 hospitalisations in OECD countries potentially caused by a medication related event. This report considers the human impact and the economic costs of medication safety events, exploring opportunities to improve systems and policies and how to improve medication safety at a national level.
  25. 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.
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