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Found 1,092 results
  1. Content Article
    This episode discusses the role NICE plays in patient safety. The guests are: Professor Kevin Harris, senior responsible office for patient safety at NICE, and clinical advisor to the Interventional Procedures Programme and Professor Jane Blazeby, Professor of Surgery at University of Bristol.
  2. Content Article
    This study by a team at the University of Derby in the British Journal of Anaesthesia used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task.  The authors found that errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays, a finding that was replicated for correct responses for error-absent trays. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.
  3. Content Article
    To date, research on adverse drug reactions (ADRs) has focused on secondary care, and there is limited studies that have prospectively examined ADRs affecting older adults in general practice. This study from Doherty et al. examined the cumulative incidence and severity of ADRs and associated patient characteristics in a sample of community-dwelling older adults. They found that over one-quarter of older adults experienced an ADR over a 6-year period. Polypharmacy is independently associated with ADR risk in general practice and older adults on ≥10 drug classes should be prioritised for regular medication review.
  4. Content Article
    The Health and Social Care Select Committee have published a new report reviewing the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. This blog sets out Patient Safety Learning’s reflections on this report.
  5. Content Article
    This Health and Social Care Select Committee report reviews the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. You can read Patient Safety Learning’s reflections on this report here.
  6. Content Article
    This video from the Irish Health Services Executive (HSE) tells the story of Barry, a paediatric nurse who made a medication error when treating a critically ill baby. Barry describes how the incident and the management response to it affected his mental health and confidence over a long period of time. He also describes how he had to fight to ensure the family were told the full story of what had happened, and the positive relationship he developed with the baby's mother as a result. The baby received the treatment they needed and recovered well.
  7. Content Article
    In this BMJ Editorial, author Sam Patel says that linking medicines information from all care settings into a shared digital medication record accessible to all health and care clinicians has the potential to substantially reduce medication errors and improve patient safety. 
  8. Content Article
    This webinar by the World Health Organization (WHO) is part of a series hosted to mark World Patient Safety Day 2022, which focused on the theme of 'Medication without harm'. This webinar looks at medication safety in polypharmacy, introducing the WHO technical report on Medication safety in polypharmacy. It features perspectives on medication management from patients, carers and national healthcare leaders.
  9. Content Article
    As global trade and the Internet keep on growing it has become much easier for people to pass goods off as genuine. Counterfeiting in medicine products is becoming more prevalent and countries are now adopting systems to protect the legitimate supply of products to protect the industry and importantly the patients. Systems are already operating in America and Germany and the EU has formulated a directive for all European countries to adopt a system that protects all European citizens. The False Medicine Directive (FMD) registration database tracks all medicines from the manufacturer through to the patient in a unified way across the whole of Europe. Across the EU those who manufacture, sell or dispense medicines must comply with new track and trace regulations. Find out more from the FMD plus website.
  10. Content Article
    The safety, effectiveness, and cost-effectiveness of molnupiravir, an oral antiviral medication for SARS-CoV-2, has not been established in vaccinated patients in the community at increased risk of morbidity and mortality from COVID-19. In this study, Butler et al. aimed to establish whether the addition of molnupiravir to usual care reduced hospital admissions and deaths associated with COVID-19 in this population. The authors conclude that molnupiravir did not reduce the frequency of COVID-19-associated hospitalisations or death among high-risk vaccinated adults in the community.
  11. Content Article
    Recording of the Health and Social Care Committee meeting held on Tuesday 13 December 2022. Meeting started at 10.03am, ended 11.45am.
  12. Content Article
    Regina Kamoga, Executive Director of the Community Health And Information Network (CHAIN) in Uganda, delivered this presentation to the 6th Annual Pharmacovigilance Stakeholder Meeting on 30 November 2022. The presentation outlines how CHAIN is working to develop and support expert patients and patient groups in underserved communities in Africa, as well as highlighting the key medication safety issues faced by these communities, including low health literacy, poor reporting culture and healthcare worker knowledge gaps. The presentation then looks at how CHAIN implemented the World Health Organization's (WHO) Global Patient Safety Challenge in Ugandan communities through patient engagement and healthcare worker education. To conclude the presentation, Regina makes recommendations to improve medication safety: Sustain advocacy for medication safety and become a voice to the voiceless Adopt a culture of safety that incorporates the patient as a care team member not a perceived receiver of care Build and strengthen networks on patient safety Communication and open discussion between healthcare providers and patients to improve patient doctor relationship Increase collaboration with civil society organisations and patient organisations Adopt Start Early In Life initiative to instil a safety culture early in life Establish medication safety multidisciplinary working group Patient, family and community engagement should be at the core of key stakeholders interventions
  13. Content Article
    Extravasation is the unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue. This can cause harm and lead to complications for the patient. This guide, produced by the Royal Children's Hospital Melbourne, includes: Introduction Aim Definition of terms Risk factors Assessment Management Irrigation Procedure Follow-up/Review Special considerations Evidence Table Companion documents References
  14. Content Article
    This policy paper, published by the Department of Health and Social Care, provides an update on the UK Government’s progress in implementing the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
  15. Content Article
    The BMJ, in partnership with the Choosing Wisely international collaboration, led by the Choosing Wisely Canada campaign, has introduced a “Change” series in the Education section. Articles in the series highlight evidence based strategies and tools to help change practice and reduce unnecessary tests, treatments, and procedures. The articles indicate why and how practice needs to change, usually focusing on one aspect of care, and are aligned with recommendations made by national Choosing Wisely campaigns.
  16. Content Article
    This is an Adjournment Debate from the House of Commons on Wednesday 7 December 2022 on fatalities relating to foetal valproate spectrum disorder.
  17. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. Venous thrombosis occurs when a blood clot forms and causes a blockage in a person’s vein. This can lead to venous thromboembolism (VTE), when part of the clot breaks off and travels through the bloodstream, blocking a blood vessel elsewhere in the body. Pregnant women and pregnant people are at greater risk of developing a venous thrombosis than those who are of the same age and not pregnant. Because of the increased risk, healthcare staff assess a pregnant woman’s risk factors for VTE at key stages before and after the birth, so that they can be given preventative treatment if necessary. While rare, in the UK venous thrombosis and VTE is the leading direct cause of death of pregnant women during pregnancy or up to six weeks after the end of pregnancy. Reference event The reference event for this investigation was the case of Alice, who was 26 years old and was pregnant with her second child. A VTE risk assessment was completed for Alice at her first antenatal appointment, when she was admitted to hospital for the birth of her child, and 24 hours after admission. Her score was zero each time, meaning no risk factors were identified for VTE. During her pregnancy Alice reported experiencing some pain in her calf; she was examined by a doctor who referred her for a scan. This ruled out a deep vein thrombosis (DVT). After giving birth by caesarean section, Alice's risk assessment was repeated, and as it indicated that medication was required, a preventative dose of low-molecular-weight heparin was prescribed and Alice was discharged. Eleven days after the birth of her baby, Alice was taken by ambulance to the emergency department with chest pain, shortness of breath and leg cramps. She was diagnosed with a pulmonary embolism (PE) and was started on a treatment dose of blood-thinning injections. Following investigation, it was found that Alice may not have received an appropriate preventative dose of low-molecular-weight heparin to help prevent the VTE.
  18. Content Article
    Extravasation is the accidental leakage of any liquid from a vein into the surrounding tissues, which can cause serious harm to the patient (NHS England, 2017). From 1 April 2011 until 31 March 2021 the NHS paid £15.6 million in damages relating to extravasation. This leaflet, published by NHS Resolution, aims to share learning from those claims.
  19. Content Article
    Medication is the main part of the therapeutic process for hospital patients and with stocks of up to 200 medications held by hospital settings, it is estimated to be the second-highest spending chapter of health budgets. Management of medication stocks, their prescription and administration to patients (better known as the “medication management pathway”) is an onerous activity for hospitals and healthcare professionals. Tasks in this pathway are largely manual and non-digitalised. Visibility of medicine stocks is low; medication data is unfindable and low digitalisation of the pathway makes it highly prone for the occurrence of medication errors. Current rates of digitalisation combined with the high rates of manual activities undermines patients and healthcare professionals’ wellbeing and hospital systems resilience. For medication errors alone, the impact from the current low levels of digitalisation in hospitals costs the OECD group $54 billion and 3 million avoidable hospital days. With the advent of the European Medicine’s Agency new European Shortages Monitoring Platform (ESMP) which will manage medication shortages and the European Health Data space for cross border patient care, current levels of Digitalisation of Hospitals Medication management pathways will reduce the reliability and success of these new initiatives to respond effectively to future health care crises. It is therefore crucial that the European Union invests in the Digitalisation of Hospitals Medication management pathways for patient safety, healthcare professionals’ wellbeing and for hospital resilience.
  20. Content Article
    Macarthys Laboratories (trading as Martindale Pharma, an Ethypharm Group Company), has notified the MHRA that a limited number of Prenoxad kits (also called packs) in a batch marketed in France have missing needles. Naloxone is a drug that reverses the effects of an opioid overdose. If no needles are present in the kit, there is a risk that patients, members of the public and/or healthcare professionals may not be able to administer life-saving doses of naloxone from these kits in an emergency. This may impede the treatment for a patient with an opioid overdose, which may result in delay to intervention and possible death. Although no reports of UK marketed kits with missing needles have been received to date, the potential for kits to contain fewer than two needles in all distributed batches cannot be excluded based on the investigation by the company. However, due to the critical need for this product, the specified batches are not being recalled. This alert is for action by: primary and secondary care, specifically those involved in outreach services.
  21. Content Article
    Patient safety is vital to well-functioning health systems. A key component is safe prescribing, particularly in primary care where most medications are prescribed. Previous research has demonstrated that the number of patients exposed to potentially hazardous prescribing can be reduced by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners (GPs) in a pharmacist-led intervention. This study aimed to develop and roll out an online dashboard application that delivers this audit and feedback intervention in a continuous fashion.
  22. Content Article
    This case study describes the project that won the 'Future-proofing Healthcare 2022' category in the Healthcare Quality Improvement Partnership's (HQIP's) Clinical Audit Heroes Awards. The Sustainable Respiratory Care Audit team at Newcastle Hospitals NHS Foundation Trust was recognised for its work improving care for individual patients while also reducing the environmental impacts of healthcare. Their nomination detailed how the project provided a structure for the audit of patients’ techniques, preferences and knowledge about inhalers, and the need for a clinical review—interventions that can reduce the carbon footprint of healthcare while improving the quality of care.
  23. Content Article
    Sarah Kay and Jaydee Swarbrick are involved in the Patient Safety in Primary Care Project in Dorset. In this blog, they summarise a recent event they held to share learning from medicines incidents.
  24. Content Article
    This blog by Dr Anna Bayes from Altera Digital Health looks at the benefits of closed-loop medication administration (CLMA) in preventing avoidable medication errors. CLMA provides an extra validation at the point of drug administration by using barcode technology to positively identify the patient and validate their prescribed medications against the physical medication product (for example, pills, infusions or creams) at the point of care. Anna also considers CLMA's role in advancing digital maturity.
  25. Content Article
    Medications and specifically fall-risk-increasing drugs (FRIDs) are associated with increased risk of falls: reducing their prescription may improve this risk. This study from Cox et al. explored patient characteristics associated with FRID use, prevalence and type of FRIDs and changes in their prescriptions among older people with arm fractures over 6 months. The study found that more than one FRID prescription had a significantly higher number of co-morbidities and medications and higher rates of male gender, polypharmacy, frailty and sarcopenia. The most frequently prescribed FRIDs were antihypertensives, opioids and antidepressants. Use of FRIDs among older people with upper limb fragility fractures was high. Although overall use decreased over time, 59% were still on 1 or more FRID at the 6-month follow-up, with trends to stop opioids and start antidepressants. Older people presenting with upper limb fractures should be offered a structured medication review to identify FRIDs for targeted deprescribing.
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