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Showing results for tags 'Adminstering medication'.
Found 34 results
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Uppsala Monitoring Centre: VigiBase
Patient Safety Learning posted an article in Adverse interactions
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Content ArticleHaving 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
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News ArticleNHS 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
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Content ArticleNasogastric (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
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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 -
Content ArticleImplementation 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
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Content ArticleThe 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
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Content ArticleI 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.
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Content ArticleRecommendations 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
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News ArticleA 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
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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 -
Content ArticleSafety 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
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Health experts criticise NHS advice to take ibuprofen for Covid-19
Patient Safety Learning posted a news article in News
Experts have criticised NHS advice that people self-isolating with Covid-19 should take ibuprofen, saying there is plausible evidence this could aggravate the condition. The comments came after French authorities warned against taking widely used over the counter anti-inflammatory drugs. The country’s health minister, Olivier Véran, a qualified doctor and neurologist, tweeted on Saturday: “The taking of anti-inflammatories [ibuprofen, cortisone … ] could be a factor in aggravating the infection. In case of fever, take paracetamol. If you are already taking anti-inflammatory drugs, ask you -
News ArticleThe 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
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How to undertake intravenous infusion calculations
Patient Safety Learning posted an article in Nursing
Key points Medication errors are the most common type of error affecting patient safety and the most common single, preventable cause of adverse events. Medicines calculations can assist in preventing an inaccurate medicines dose from being administered to the patient, which could result in suboptimal therapeutic benefit and/or possible harm to the patient. It is crucial for IV infusion calculations to be accurate, because these medicines directly enter the venous system and generally have a prompt action. Therefore, there is limited possibility of removing the medicine if an
