Search the hub
Showing results for tags 'Adminstering medication'.
-
Content Article
Having accurate patient information (for example, age, allergies, laboratory results) helps practitioners select medications, doses and routes of administration. One vital piece of information, the patient's weight, is especially important, because it is used to calculate the appropriate dose of a medication (for example, mg/kg, mcg/kg, mg/m2). A prescribed or dispensed medication dose can differ significantly from the appropriate dose because of missing or inaccurate patient weights. Patients in oncology treatment, patients with renal insufficiency, or who are elderly, paediatric or neon- Posted
-
- USA
- Adminstering medication
-
(and 2 more)
Tagged with:
-
News Article
NHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients. The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk. The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years. H- Posted
-
- Recommendations
- Investigation
-
(and 2 more)
Tagged with:
-
Content Article
Nasogastric (NG) tubes placed incorrectly, going undetected and delivering food, liquid or medication into the lungs is a well-recognised never event in the NHS. Despite safety alerts and various safety initiatives, the investigation identified that this type of never event continues to happen and that there are not strong ‘systemic’ barriers to prevent NG tubes being accidentally placed into the lungs. Data from national reporting systems shows that there were 14 incidents of misplaced NG tubes from April to September this year. The report acknowledges that measures carried out to tackle- Posted
-
- Investigation
- Recommendations
-
(and 2 more)
Tagged with:
-
Event
Managing patient safety across the sedation continuum
Patient Safety Learning posted a calendar event in Community Calendar
Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a group of experts, including pharmacists, anesthesiologists, respiratory therapists, family members, and nursing leaders, to explore the patient safety priorities of sedation, opioid therapy and respiratory depression. The group will discuss frequently encountered safety issues, explore organisational processes to reduce sedation safety events, and assess the role patients and family members can play in reducing harm. Register- Posted
-
- Adminstering medication
- Anaesthesia
-
(and 1 more)
Tagged with:
-
Content Article
Implementation challenges The investigation highlighted the main implementation challenges. This includes: National consistency in drug libraries – smart infusion pumps have an inbuilt dose error reduction system (DERS) which requires the use of a drug library. The investigation found that drug libraries were developed ‘locally’ and that there is no agreed national drug library for use in NHS. They also found that there is no national guidelines or standards on how to implement the libraries. Significant changes in processes – introducing the technology requires significant cha- Posted
-
- Investigation
- Adminstering medication
- (and 5 more)
-
Content Article
The objectives of the Medication Errors Group are aligned with and expand on WHO Medication Safety Objectives as follows: To create opportunities for those researching and investigating medication errors to network in a friendly and mutually supportive environment and disseminate their research using good quality outlets. To support healthcare professionals and/or organizations with scientific evaluation of medication errors and how to prevent them. To promote and develop teaching and education about all aspects of medication errors including their mitigation as part of pharm- Posted
-
- Medication
- Adminstering medication
- (and 3 more)
-
Content Article
I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.- Posted
- 1 comment
-
- Monitoring
- Treatment
-
(and 21 more)
Tagged with:
- Monitoring
- Treatment
- Adminstering medication
- Observations
- Learning disabilities
- Patient death
- Communication problems
- Omissions
- System safety
- Accountability
- Leadership
- Organisational culture
- Organisational Performance
- Transparency
- protocols and procedures
- Risk assessment
- Autism
- Clinical governance
- Complaint
- Investigation
- Legal issue
- Root cause anaylsis
- Coroner reports
-
Content Article
Recommendations As a result of the national investigation, HSIB has made three safety recommendations to facilitate better understanding of the role of the ward-based pharmacist, and to encourage best practice and resilience when identifying and developing models of pharmacy provision. It is recommended that NHS England and NHS Improvement carry out work to understand and further define the work of hospital clinical pharmacy teams, including the period between initial medicine reconciliation and discharge, in consultation with relevant stakeholders. It is recommended that the R- Posted
-
- Adminstering medication
- Investigation
- (and 3 more)
-
News Article
NHS hospitals ordered to remove drug after mistakes led to two baby deaths
Patient Safety Learning posted a news article in News
All NHS hospitals in England have been told to destroy a powerful medicine mistakenly used by staff because its packaging looks the same as another drug. A national safety alert was issued following several incidents, including two deaths of babies, in which patients were inadvertently given a dose of sodium nitrite – which is used as an antidote to cyanide poisoning – rather than sodium bicarbonate. The errors are thought to have been caused by similarities between the labelling and drug packaging used by manufacturers. Now hospitals have been told to check all wards and medicine st -
News Article
Chronic pain sufferers should not be given opioids, says medicines watchdog
Patient Safety Learning posted a news article in News
People with chronic pain that can’t be explained by other conditions should not be prescribed opioids because they do more harm than good, the medicines watchdog has warned. The National Institute for Health and Care Excellence (NICE) has said people should instead be offered group exercise, acupuncture and psychological therapy. In new draft guidance, NICE said most of the common medications used for chronic primary pain has little or no evidence to support their use in patients aged over 16. Its latest guidance comes amid concerns over the level of opioid use. In September las- Posted
-
- Substance / Drug abuse
- Adminstering medication
-
(and 1 more)
Tagged with:
-
Content Article
Medication safety: "Know Check Ask"
Claire Cox posted an article in Resources for patients
- Posted
-
- Patient
- Medication
-
(and 1 more)
Tagged with:
-
News Article
A shortage of contraception is causing chaos and risks unplanned pregnancies and abortions, doctors are warning. Leading sexual health experts have written to ministers warning that the supply shortage of contraceptives is beginning to lead to serious problems across the UK. A number of daily pills and a long-acting injectable contraceptive are thought to be affected, including Noriday, Norimin and Synphase. The problem follows a shortage of hormone replacement therapy for menopausal women last year. It is unclear how many women use these types of contraception - overall around -
Content Article
Safety recommendations: It is recommended that NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System. It is recommended that NHSX supports the development of interoperability standards for medication messaging. It is recommended that NHSX continues its assessment of the ePRaSE pilot and considers making ePRaSE a mandatory annual reporting requirement for the assessment and assurance of electronic prescribing and medicines administration safety. It is recommended that the Department of Health and Social- Posted
-
- Prescribing
- Medicine - Clinical pharmacology
- (and 2 more)
-
News Article
The toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, a new report warns today. The Healthcare and Safety Investigation Branch (HSIB) report focuses on propranolol, a cardiac drug that is now predominately used to treat migraine and anxiety symptoms. It is highly toxic when taken in large quantities and patients deteriorate quickly, making it difficult to treat. The investigation highlighted that these risks aren’t known widely enough by medical staff across the health service, whether issuing prescriptions to at risk p- Posted
-
- Prescribing
- Patient death
- (and 5 more)