Search the hub

Nudges are subtle changes to the way options are presented to guide choice. These have been employed in healthcare systems to improve clinical decisions.  This systematic review analyses six randomised controlled trials investigating overuse of opiods, antibiotics, high-risk medicines for older patients and imaging during palliative radiotherapy, in order to examine the effect of clinician-directed default nudges on overuse of tests or treatments. It was found that clinician-directed default nudges had inconsistent effects on overuse of healthcare, suggesting that high quality trials are required to determine whether default nudges reduce overuse or improve patient outcomes. 

This Health Services Safety Investigation Body (HSSIB) report examines patient safety in relation to electronic prescribing and medicines administration (ePMA). ePMA is software used to prescribe medication and create a record of the medication: that has been given, or due and not given to a patient. Most people admitted to hospital will receive medication, and most acute hospital trusts in England have ePMA functionality in at least part of their organisations. This report focuses on the procurement process used by acute hospital trusts to purchase new ePMA functionality and/or upgrade their existing ePMA functionality and how patient safety learning about ePMA is identified and shared across the healthcare system. It considers how legal, regulatory, standards and assurance functions apply in relation to ePMA safety. ePMA functionality has been shown to reduce some medication errors. However, the current national mechanisms (legislation, regulation, standards and assurance) for ensuring patient safety in relation to ePMA functionality may not adequately provide staff and healthcare organisations with the assurance that risk and hazard identification process are robust and/or share learning associated with the use of ePMA in an acute hospital setting. Findings There are no core national patient safety standards that inform either the design or procurement of ePMA. This can lead to unwarranted variation in functionality across and between ePMA, other electronic systems, and acute hospital trusts, which may pose challenges for staff when prescribing and administering medication. Current assurance mechanisms do not provide national oversight or enforcement of either manufacturer or healthcare provider compliance with legally mandated standards relating to digital clinical safety and interoperability of digital health technology. The safety risks associated with software such as ePMA are complex and may change rapidly. Legislation, regulation and standards may not keep up with the speed of technological change. Manufacturers must self-assess and report whether their ePMA is compliant with relevant standards for their products to be included on an NHS procurement framework. There is variation in the core safety standards identified by acute hospital trusts when procuring and contracting for ePMA functionality. This leads to trusts identifying safety requirements individually, with limited consistency in the approach taken across trusts. Reliance is placed on acute hospital trusts to determine whether ePMA manufacturers have interpreted the medical device regulations appropriately, and to assure themselves that the trust complies with relevant standards. Some trusts do not have the resources, skills and expertise to do this effectively. Digital safety and patient safety teams at local and national level may work in silos, with limited ability to share information or collaborate on ePMA-related decisions that impact on patient safety. There are challenges with identifying national safety learning relating to ePMA as this is not reliably captured, shared or identified through formal reporting routes. There is ongoing work to improve the NHS reporting system to capture digital-related patient safety incidents. There is a reliance on informal networks for sharing ePMA safety issues which means safety concerns may not always be shared with those who need to be aware. Some ePMA manufacturers, whose ePMA functionality is not registered as a medical device choose to apply equivalent governance and assurance measures as if it is a medical device. This is in addition to complying with the digital clinical safety standard (DCB0129). Acute hospital trusts face challenges prioritising and resourcing procurement decisions for ePMA functionality. This leads to challenges and patient safety issues when ePMA is implemented. Clinical safety officers (CSOs) may not be adequately resourced, meaning they have limited capacity to support in managing clinical risks associated with ePMA. There is variation in how the CSO responsibilities set out in the digital clinical standards are interpreted and implemented by trusts. NHS England is working on plans for a formal curriculum and potential accreditation to improve CSO skills and capabilities. HSSIB makes the following safety recommendations Safety recommendation R/2026/086: HSSIB recommends that the Medicines and Healthcare products Regulatory Agency ensures that: routes for manufacturers and healthcare organisations to engage with them are clear and accessible it reviews and provides further guidance and clarification on when electronic prescribing and medicines administration (ePMA) software should be considered a medical device. This will support how ePMA software can be appropriately classified and regulated to improve patient safety. Safety recommendation R/2026/087: HSSIB recommends that NHS England/Department of Health and Social Care establishes a national framework for core electronic prescribing and medicines administration (ePMA) safety. This will provide a clear set of minimum patient safety requirements, helping to reduce unwarranted variation in the safety of ePMA functionality. Safety recommendation R/2026/088: HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance processes. Safety recommendation R/2026/089: HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to: supporting healthcare providers to access digital clinical safety knowledge, capacity and capability integrating digital clinical safety and patient safety, including the associated terminology supporting robust assurance of whether electronic prescribing and medicines administration (ePMA) manufacturers comply with relevant standards in order to be considered for inclusion on an NHS procurement framework. This will support effective decision making and oversight by acute hospital trusts and reduce unwarranted variation in the understanding of, and approach to, adopting ePMA. Safety recommendation R/2026/090: HSSIB recommends that the Care Quality Commission reviews the sector-level assessment frameworks it is developing to include assurance of ongoing compliance with the digital clinical safety standard (DCB0160) for electronic prescribing and medicines administration (ePMA) software. This will help to ensure oversight of ePMA functionality to improve patient safety. HSSIB makes the following safety observations Safety observation O/2026/086: Commercial manufacturers can improve patient safety by applying the standards and expectations for a medical device when developing electronic prescribing and medicines administration (ePMA) functionality, to help provide further assurance to acute hospital trusts procuring or updating ePMA functionality. Safety observation O/2026/087: Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums. Safety observation O/2026/088: Commercial manufacturers and NHS organisations can improve patient safety by contributing to and engaging with ePRaSE (ePrescribing Risk and Safety Evaluation) processes to support ongoing improvement and optimisation of electronic prescribing and medicines administration (ePMA) functionality across the NHS.

This Health Services Safety Investigations Body (HSSIB) report considers the safe administration of insulin for people with known diabetes mellitus, who may be at risk of harm during admissions to hospital. HSSIB are undertaking a series of investigations that explore risks to patient safety for patients with diabetes in the community who self-administer insulin, and who may be at increased risk of harm because of their circumstances. While the findings of the report are about insulin and diabetes care in acute settings, they may also be applicable in other healthcare settings and for other physical long-term conditions. Going into hospital can create risks for patients with diabetes. Patients have come to harm or died in hospital because their diabetes requiring treatment with insulin has not been appropriately managed. Hearing and reviewing the experiences of those affected led the investigation to examine the following in relation to the patient safety issue: How staff are supported to monitor and care for patients with known diabetes on a hospital ward. How patients are supported to safely self-administer their insulin (through injections or via a pump or hybrid closed loop system), as part of a diabetes self-management regime. What national recommendations/observations have been made to date and the outcomes seen. The investigation’s findings are offered to support improvements in services for patients who are admitted to hospital and require ongoing care for their diabetes that requires insulin therapy. Findings Integrated care board (ICB), regional and national oversight for inpatient diabetes care is fragmented, and assurance for patient safety is devolved to individual trusts. This leads to gaps in responsibility and accountability for implementing national guidance and recommendations, and for acting on national audit data, for improvement of patient safety. Regulatory activity requires strengthening to effectively assess and address safety concerns relating to inpatient diabetes care. Local hospital oversight structures required by national guidance and recommendations, such as diabetes safety boards, are often absent. This can hamper local-level oversight and mitigation of risks, increasing risks to inpatients who have diabetes. Prioritisation and funding of inpatient diabetes care at the hospital and ICB level has not supported the full implementation of national guidance and recommendations. Participation in the National Diabetes Inpatient Safety Audit is low, limiting the ability to track trends, benchmark performance, or drive strategic and nationwide diabetes care improvements. Most inpatient diabetes care is delivered by non-specialists who may lack confidence and/or competence in diabetes management. Specialist diabetes teams are often under-resourced and unable to provide 7-day coverage to support non-specialist staff and care for patients. Even at recommended staffing levels, specialist teams cannot always see every patient who may need support. Diabetes/insulin awareness training for non-specialist staff and students is inconsistent. Education gaps persist at both trust and undergraduate levels, with no national minimum mandated standard for diabetes care or insulin safety education, training and competency assessments. Many hospital clinicians, along with national stakeholders, strongly support adding blood glucose levels to the National Early Warning Score (NEWS2) to improve the detection of diabetes-related patient deterioration, but acknowledge challenges in doing so. Many patients who safely self-administer insulin at home through injection, insulin pumps, or hybrid closed loop systems, are prevented from doing so in hospital. This can be due to local policies on diabetes self-management and insulin self-administration, and the reluctance of staff to allow patients to self-administer because they fear being blamed if things go wrong. Lack of clarity about safe bedside storage of insulin and misconceptions about the regulatory stance on this create barriers for patients to self-administer. Networked glucose meters can improve safety, but implementation of required hardware and software is inconsistent. There is limited integration between hospital networked glucose meters and electronic patient records, creating potential blind spots in inpatient diabetes care. HSSIB makes the following safety recommendations Safety recommendation R/2026/076: HSSIB recommends that NHS England/Department of Health and Social Care sets out the expectations and responsibilities of NHS trusts, integrated care boards and NHS England for the oversight and assurance of inpatient diabetes care. This should support organisations to implement and act on improvements shared in national guidance, recommendations and audit data. It should also include how existing functions (Getting It Right First Time and the Diabetes Care Accreditation Programme), and those currently in development (new National Diabetes Audit for Inpatient Care) can be more closely aligned and utilised to help better understand and respond to challenges relating to the safety and quality of inpatient diabetes care. Safety recommendation R/2026/077: HSSIB recommends that the Royal College of Physicians reviews and acts on new data and outcomes of studies about adopting blood glucose into NEWS2 and shares any decisions it makes. This is to encourage understanding and support consideration of how blood glucose issues can be recognised early and escalated to mitigate harm. Safety recommendation R/2026/078: HSSIB recommends that the Care Quality Commission assesses how it can use data from the Diabetes Care Accreditation Programme and the new National Diabetes Audit for Inpatient Care as part of its regulatory activity. This is to ensure that known challenges in inpatient diabetes care, and knowledge of providers that do not report national diabetes audit data, are considered to provide intelligence in support of regulatory activity. HSSIB makes the following safety observations Safety observation O/2026/083: Organisations and individuals involved in the provision of clinical undergraduate and pre-registration education, and trust preceptorship/induction programmes, can improve patient safety by using the findings of this report to prioritise diabetes care and insulin management education and training as appropriate. Safety observation O/2026/084: Professional regulators and royal colleges can improve patient safety by reviewing this report and disseminating appropriate communications to their registrants and members in relation to understanding their expectations in providing safe diabetes care. HSSIB suggests safety learning for integrated care boards HSSIB investigations include safety learning for integrated care boards where this may help organisations think about how to respond to a patient safety issue that relates to integrated care across a geographical footprint. Informed by the findings in this report, the investigation proposes the following safety learning. Safety learning for integrated care boards ICB/2026/016: HSSIB suggests that integrated care boards consider the findings of this report to inform funding prioritisation decisions for trust diabetes specialist inpatient services. This is to help support the delivery of safe inpatient diabetes care through appropriately staffed 7-day inpatient diabetes specialist services to mitigate patient harm. Local-level learning HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has developed the following prompts to support local-level learning for NHS trusts. Self-management of diabetes and insulin administration Do you have a policy that supports patients to safely self-manage their diabetes and support self-administration of insulin? Is your policy clear, available, and does it enable clinicians to support safe self-management and self-administration? Are the timing and content of meals considered in support of patients self-managing their diabetes? Is safe bedside storage of insulin provided to support self-administration? If not, how could this be supported? Are clinicians aware of national guidance and the regulatory stance regarding promotion of safe self-management of diabetes and insulin administration? Diabetes specialist workforce and capacity Is your inpatient diabetes specialist team appropriately resourced to help mitigate known diabetes-related risks? Is your diabetes inpatient specialist team supported to operate out of hours, such as over weekends and bank holidays? Non-specialist diabetes care Do you protect education and training time for diabetes training? Does your diabetes training ensure key risks to inpatients with diabetes are highlighted to staff? Do you have a diabetes specialist team that is appropriately resourced with sufficient capacity to deliver diabetes education and training? Hospital diabetes technology Do you have networked glucose meters to support remote monitoring of patients with diabetes? Do the glucose meters in your hospital automatically upload data to electronic patient records, and does this support remote monitoring of patients? Does your inpatient diabetes specialist team access diabetes related reports/alerts daily to identify patients at risk? Do you provide digital tools or apps to support your non-specialist clinicians in providing safe diabetes care? Wearable diabetes technology Do you have a wearable diabetes technology element in your diabetes education and training programme? Do you have clear and available guidance on wearable diabetes technology for your non-specialist clinicians? Oversight and governance Do you participate in the Diabetes Care Accreditation Programme (DCAP)? Do you submit data to the National Diabetes Inpatient Safety Audit (to be superseded by the National Diabetes Audit for Inpatient Care)? Do you have a diabetes safety board with senior management involvement? Does your diabetes safety board work with your inpatient diabetes specialist team to understand key diabetes risks and issues? Does your diabetes safety board have the authority to agree actions and prioritise resources for their implementation?

Double-checking of medication administration is a safety practice used in hospitals around the world. Independence is recommended as the key to effectiveness. Independent double-checking (IDC) requires each nurse to separately check the five rights (eg, right drug, dose). There is no empirical evidence that IDC is more effective in error detection than a single-nurse check. The aim of this study was to compare the effectiveness of IDC versus single-checking in detecting medication errors during administration, assess the time required and explore factors influencing performance, including nurse experience and social dynamics. It found that IDC improved error detection for experienced nurses, but not for early career nurses. Given its inconsistent benefits, resource demands and susceptibility to social loafing (defined as reduced individual performance when working in pairs), IDC may be unsuitable as a universal safety strategy. Strengthening single-checking competence and supporting clinical judgement may offer a more effective, scalable approach to improving medication safety.

This Health Services Safety Investigations Body (HSSIB) report is the first in a series considering the self-administration of insulin by people with diabetes mellitus (diabetes) in community settings. It focuses on adults with a mental health problem who are known to or under the care of secondary mental health services (specialist services provided in the community), who have been harmed when they have not self-administered their prescribed insulin as intended – this is referred to as the patient safety issue in this report. People have come to harm or have died as a result of self-administering too much insulin and/or not self-administering insulin when it is needed. Hearing the experiences of all those affected led the investigation to examine the following in relation to the patient safety issue: collaboration between mental health and specialist diabetes services care for patients experiencing a mental health crisis access to insulin devices and technology. Findings Findings related to collaboration between mental health and specialist diabetes services Patients with a mental health problem and diabetes (requiring treatment with insulin) in the community are not always under the care of specialist diabetes services when this would be expected in their care (for example patients with type 1 diabetes). Patients have been discharged from specialist diabetes services after missing one or more appointments (‘did not attend’). Patients may be discharged without consideration of their circumstances and clinical risk. Patients have disengaged from specialist diabetes services when adjustments have not been made for their mental health needs. Services had limited access to support from specialist mental health teams. Community mental health teams feel responsible for their patients’ diabetes care when they are not under the care of a specialist diabetes service. Teams have limited routes through which to access support around insulin management. There is variable integration of mental health and specialist diabetes services in different parts of the country. This is despite recognition of the disconnect between services and the risks to patient safety and physical health. Digital integration between mental health and specialist diabetes services is also variable. This has created barriers to information sharing and has contributed to patient safety incidents. Integrated care boards face barriers – such as resource limitations, workforce shortages and separated policy teams – to developing integrated arrangements between mental health and specialist diabetes services. There are unclear national plans for the long-term integration of mental health and physical health services, with limited national collaboration between relevant policy teams to address the issues. There continues to be no effective mechanism to allow regulatory oversight of care pathways that span different providers/organisations, such as for integrated mental health and diabetes care. The combination of type 1 diabetes and disordered eating (T1DE) contributes to significant patient harm. There are varying views about whether T1DE is a specific condition, and research gaps around the identification of and care for patients with T1DE. Long-term funding for T1DE services is at risk due to factors including their cost, highly specialist nature and concerns about limiting access to services for other people with diabetes and a mental health problem. People experiencing homelessness face challenges accessing the support they need for their mental health and diabetes. Limited data on the need for services influences investment, and prejudice may be a factor. Findings related to access to insulin devices and technology There are no insulin pen devices designed in such a way that would prevent a patient from intentionally self-administering excess insulin. Limitations in data collected by manufacturers and national organisations means the patient safety issue in this investigation may not be apparent to manufacturers. Changes to insulin pen device design in response to patient safety issues may not be considered when the issues have arisen through use of the device outside of its intended purpose. Some patients may be being disadvantaged by not being considered for continuous glucose monitoring or hybrid closed loop systems due to their mental health problem. Findings related to care for patients experiencing a mental health crisis Community mental health teams face barriers that prevent them from forming therapeutic relationships with patients and therefore the making of safety plans should the patient feel the urge to self-harm. People with a diagnosis of personality disorder face challenges accessing specialist mental health services that are able to meet their specific needs. Mental health teams may not fully recognise the risks of self-harm associated with access to different types of insulin. This is not consistently covered in pre-registration mental health practitioner training. Care planning does not always consider the safeguarding of patients who experience rapid and extreme fluctuations in their emotions and mental capacity, placing them at risk of self-harm. Information supportive of a patient’s safety may be withheld from their family – as a result of the patient declining sharing – without staff considering the context, and the patient's mental capacity and whether they recognise the potential benefits and risks of the decision. HSSIB makes the following safety recommendations Safety recommendation R/2026/073: HSSIB recommends that NHS England/Department of Health and Social Care develops a strategy for improving collaboration between mental health teams and specialist diabetes services, that includes consideration of responsibilities for integrated working at national, regional and local levels. This is to support future integration of services that will benefit all patients with mental health and diabetes care needs, including patients who are required to self-administer insulin and patients with type 1 diabetes and disordered eating. Safety recommendation R/2026/074: HSSIB recommends that the National Institute for Health and Care Research, in collaboration with relevant research and policy stakeholders: maps the knowledge gaps surrounding type 1 diabetes and disordered eating (including those identified in this investigation) assesses the priority and feasibility of commissioning research to help address those gaps. This is to help develop new knowledge to inform future decisions for the delivery of safe and effective care for this group of patients. Safety recommendation R/2026/075: HSSIB recommends that Royal College of Psychiatrists, through collaboration with relevant stakeholders, develops a strategy that: supports consistent recognition of patients with type 1 diabetes and evidence of disordered eating; and identifies associated care responsibilities for providers of mental and physical health services. This is to help improve the NHS’s recognition of patients who are affected and to support decisions around the commissioning of services. HSSIB makes the following safety observations Safety observation O/2026/081: Organisations involved in the provision of undergraduate and pre-registration education and preceptorship/induction programmes can improve patient safety by ensuring that staff have knowledge of diabetes, an understanding of how and why insulin is a vital treatment for many people with diabetes, and the risks that the use and misuse of insulin can present for patients with a mental health problem. Safety observation O/2026/082: Organisations involved in the manufacture of insulin pen devices used by the NHS can improve patient safety by: understanding where devices are being used outside of their intended purpose exploring the potential to design devices that would reduce the risk of intentional overdose of insulin for self-harm. HSSIB suggests safety learning for integrated care boards HSSIB investigations include safety learning for integrated care boards where this may support the response to a patient safety issue across a geographical footprint. Safety learning for integrated care boards ICB/2026/014: HSSIB suggests that integrated care boards formalise collaborations between mental health and specialist diabetes services in their local systems. Through co-production with people with lived experience, this should look to include: care arrangements for people with a mental health problem and diabetes, particularly for those who require insulin routes for community mental health teams to access advice where their patients have diabetes and access to insulin routes for diabetes specialist teams to seek advice from mental health teams about reasonable adjustments for patients under the care of outpatient clinics enablement of interoperability between electronic systems to support information sharing. Safety learning for integrated care boards ICB/2026/015: HSSIB suggests that integrated care boards develop data-driven approaches for the understanding of local need to inform decisions about services for patients who have been identified as marginalised in this investigation. These are patients with: co-existing mental health and long-term physical health needs (diabetes), including those with a diagnosed personality disorder and/or experiencing homelessness type 1 diabetes and disordered eating. Local-level learning HSSIB investigations include local-level learning where this may help providers/organisations respond to a patient safety issue at the local level. For organisations providing mental health and/or specialist diabetes services: Does your organisation have a specific job role with responsibility for cross-organisational care pathways to ensure the holistic needs of patients, including those with mental health problems and diabetes, are met? How does your organisation ensure information about patients is available to other providers of care when required, for example to mental health teams about a patient’s diabetes care? How does your organisation ensure staff are aware of their responsibilities to report incidents associated with diabetes medication and technology, including to manufacturers and the Medicines and Healthcare products Regulatory Agency? Does your organisation have a process for identifying and appropriately supporting patients with type 1 diabetes who also have evidence of disordered eating? For organisations providing specialist diabetes services: How does your organisation ensure patients with a mental health problem are not being discharged from clinics following a ‘did not attend’ without consideration of their circumstances and risks to their safety? Do your staff recognise the need to make reasonable adjustments for patients, including for those with a mental health problem, to support access to care? Does your organisation have a liaison psychiatry service that supports inpatient and outpatient services for people with a mental health problem? Does your organisation have clear routes via which services can seek support from specialists in mental health if a patient is found to be experiencing a crisis? How does your organisation identify patients who have had recurrent admissions with diabetic ketoacidosis or hypoglycaemia, and support staff to consider whether these patient require input from mental health services? How does your organisation ensure patients with a mental health problem, who meet the criteria for diabetes technology, are receiving support to access it and are not being discriminated against because of their mental health problem? For organisations providing mental health services: How does your organisation ensure staff working in the community have access to advice about a patient’s physical health, including specialist advice for conditions such as diabetes requiring treatment with insulin? How does your organisation keep staff up-to-date about the different types of insulin used in the NHS and their onset times to ensure this is considered as part of assessment of a patient’s risk of self-harm? How does your organisation enable staff to work therapeutically with patients to support them to develop safety plans which include consideration of the risks associated with insulin? How does your organisation support multidisciplinary discussion in discharge planning that recognises the circumstances a patient is being discharged into to ensure they are appropriate for their mental and physical health needs? How does your organisation support staff to make assessments under the Mental Capacity Act, with particular consideration of whether the patient can use and weigh information as part of their decision making? Does your organisation provide services that effectively meet the needs of people with rapidly fluctuating and extreme emotions, and that consider how best to support these patients when they are unable to make decisions to keep themselves safe? Do your staff recognise the importance of family involvement in patient care, and where the patient refuses this, do staff ensure the reasons for refusal and the potential ramifications are explored and it is appropriately revisited over time? How does your organisation support staff to not make assumptions about patients based on their circumstances and characteristics?

Medication administration errors represent a significant yet preventable cause of patient harm in the peripartum period. Implementation of best practices can significantly reduce medication errors and associated patient harm. Cases of medication errors involving unintended intrathecal administration of tranexamic acid highlight the need to improve medication safety in peripartum patients and obstetric anaesthesia. In obstetric anaesthesia, medication errors can include wrong medication, dose, route, time, patient or infusion setting. These errors are often underreported, have the potential to be catastrophic, and most can be prevented. Implementation of various types of best practice cost effective mitigation strategies include recommendations to improve drug labelling, optimise storage, determine correct medication prior to administration, use non-Luer epidural and intravenous connection ports, follow patient monitoring guidelines, use smart pumps and protocols for all infusions, disseminate medication safety educational material, and optimize staffing models. Vigilance in patient care and implementation of improved patient safety measures are urgently needed to decrease harm to mothers and newborns worldwide.

When people with Parkinson’s disease (PD) are admitted to hospital, control of their symptoms can deteriorate, often due to delayed or incorrect medication administration. The aim of this project was to improve the administration of PD medicines for hospital in-patients in Northumbria Healthcare NHS Foundation Trust. Specifically, the authors of the study aimed to administer 95% of PD medicines within 30 minutes of the prescribed time and to eliminate delays of >60 minutes for PD medications. To achieve these aims, the authors developed a multifaceted quality improvement project, led by a multidisciplinary team, that ran over a period of 2 years. The outcome measure in this project was the time delay between the time a given PD medicine was scheduled to be administered and the time at which it was recorded as having been administered by nursing staff. The project demonstrated a significant reduction in delays in medicines administration for patients with PD. The success of the project came from the cultivation of multiprofessional ‘ownership’ of the problem, in combination with an appreciation of the patient’s lived experience, through visualisation of how poor symptom control can impact on a person’s ability to move. Whilst it is not possible to comment on the long-term sustainability of the project, the authors were encouraged that the changes were maintained throughout the 6-month sustain phase for both medicine administration targets. Further reading on the hub: Top picks: 16 resources about Parkinson’s

Standardised nomenclature for combination formulations could “minimise confusion and prevent medication errors”, suggests the authors of this study. The authors identified 26 combination formulations with ‘co-drug’ names in the UK. Eleven were prescribed more than 2,000 times during 2023, including paracetamol + codeine (co-codamol), which saw an average of 1.26 million items dispensed each month; carbidopa + levodopa (co-careldopa – 114,656 items a month); dihydrocodeine + paracetamol (co-dydramol – 110,506 average monthly items; and amoxicillin + clavulanic acid (co-amoxiclav), with an average of 106,504 items a month. A literature review found examples of errors involving, with decreasing frequency, co-amoxiclav, co-amilofruse, co-beneldopa, co-careldopa, co-codamol, co-dydramol and co-trimoxazole.  The authors noted that packaging of co-drugs can also be inconsistent. For example, some co-codamol products do not prominently display the individual active ingredients, while the strength is unclear on others. To reduce the risk of errors, the authors advocate a standardised nomenclature on the box and in prescribing resources so that the international non-proprietary name (INN) of each component is followed by the strengths in the x + y format. 

This multi-award winning video*, produced in 2003 was commissioned by the office of Sir Liam Donaldson and produced by UCL Images, a video production centre based at University College London. The video illustrates updated guidance from the Department of Health on safe administration of intrathecal administration. *Please note that this is a copy of the video as this video is no longer available to order from the Department of Health. The video clip has been made publicly available from a poster on YouTube.

This article by BD looks at the the risks related to irritants and vesicants when medications are administered to patients via vascular access (into their blood vessels through a cannula). It highlights the immediate risks of vein irritation, pain, discomfort and potential tissue damage during an infusion, as well as looking at the impact of damage to vascular endothelial cells caused by irritants and vesicants. It offers guidance on selecting the right vascular access device (VAD) and includes a Vascular Access Device Assessment Decision Tree, which is free to download.

Drug-related errors are a leading cause of preventable patient harm in the clinical setting. Chan et al. present the first wearable camera system to automatically detect potential errors, prior to medication delivery. The authors demonstrate that using deep learning algorithms, the system can detect and classify drug labels on syringes and vials in drug preparation events recorded in real-world operating rooms. They created a first-of-its-kind large-scale video dataset from head-mounted cameras comprising 4K footage across 13 anaesthesiology providers, 2 hospitals and 17 operating rooms over 55 days. The system was evaluated on 418 drug draw events in routine patient care and a controlled environment and achieved 99.6% sensitivity and 98.8% specificity at detecting vial swap errors. These results suggest that the wearable camera system has the potential to provide a secondary check when a medication is selected for a patient, and a chance to intervene before a potential medical error.

Rizwana Dudhia shares in the Pharmaceutical Journal how a project she initiated to prevent the prescribing of inappropriate medication improved the quality of life for patients with learning disabilities and autism.

Medication error may occur for a variety of reasons. One of the most common sources of medication error is related to look-alike and sound-alike (LASA) drugs as well as the often-similar appearances of the vials. LASA medications are typically thought of as medications that are similar in physical appearance related to packaging as well as medications whose names are similar in spelling or in the phonetic pronunciation.  Tricia A. Meyer looks at cases of LASA drugs and prevention techniques. She concludes that healthcare professionals, safety groups, and professional organisations should continue to work with manufacturers, regulators, and naming entities to explore opportunities to minimise the LASA risks for drugs that are either new to the market or in the pre-marketing stage. Further information on the hub Take a look at our Error traps gallery on the hub

This report summarises the findings arising from a comprehensive study of antibiotic ‘line flushing’ and disposal practices in NHS organisations across Great Britain. It argues that is a need for concerted, UK-wide action on antibiotic line flushing policies. ‘Line flushing’ is the act of pushing an appropriate diluent, such as saline, through the tubing connecting patients with infusion bags which contain medicines. Up to 1/3rd of the total dose prescribed by clinicians can remain sequestered in un-flushed tubing, resulting in patients receiving too little of the antibiotic they need to fight infection. This acts as a driver for antimicrobial resistance (AMR), potentially making patients more susceptible to future drug-resistant infections (DRIs) with their associated morbidity, mortality, and costs to the NHS. This report highlights the following findings in relation to this: Fewer than 1 in 3 (29.1%) responding NHS organisations across Great Britain have an antibiotic line flushing policy. Of these, only a minority (43.8%) are fully compliant with their own policies. Overall, only 12% of NHS organisations in Great Britain—fewer than 1 in 8—are fully compliant with their own established antibiotic line flushing policies. Fewer organisations still have audited compliance in a measurable way: only 1 in 20 (5.1%) responding NHS organisations have done so. Scotland leads the way in designing and implementing antibiotic line flushing policies, followed by Wales, with English NHS organisations trailing behind. A large number of NHS organisations do not engage in line flushing dispose of antibiotics inappropriately, such as in unsealed containers (e.g. medical waste bags). A substantial proportion of NHS organisations in Great Britain dispose of administration sets in unsealed containers such as medical waste bags. In addition, a small minority of NHS organisations in Great Britain (up to 17.3%) do so without separating the spike from the administration set, against organisational policies to dispose of spikes in sharps bins and thus potentially causing occupational hazards. The report makes five policy recommendations: That all NHS organisations implement line flushing policies by late 2024, with support from the Department for Health and Social Care. That national regulators integrate adherence to line flushing policies into their assessment framework when assessing hospitals. That Government funds be made available to enable research into underdosing’s impact on DRIs and environmental AMR. That comprehensive training be provided to all appropriate staff surrounding how to dispose of antibiotics appropriately. That hospitals monitor environmental antibiotics contamination, both in effluent and on wards. Related reading Short-term intermittent IV antibiotics – Understanding the issue of under delivery Understanding the importance of accurate antibiotic administration through an IV administration set (drip): A patient’s guide Top picks: 10 key resources on antimicrobial resistance

Ambulatory infusion pumps are small, battery powered devices that allow patients to carry out day-to-day activities while receiving medication. They are used for many healthcare needs, including symptom relief during palliative care, and in different settings including hospitals, hospices and patients’ homes. Despite having audio and visual warning alarms to notify when medication is not being delivered as it should be, there is a risk that alarms can go unnoticed, particularly by healthcare staff in inpatient settings. The patient case in the Health Services Safety Investigations Body (HSSIB) investigation report is Stephen, a 45-year-old cancer patient on palliative care in hospital, who did not receive his pain relief medication for six hours. Over the course of six hours, there were eight warnings. The investigation An investigation was carried out to explore factors that can affect the ability of patients to reliably receive their medication via an ambulatory infusion pump. The focus was on this specific type of device as they are used widely across healthcare providers in England for patients receiving palliative care. The investigation uses ‘hazard’ to describe something that has the potential to cause harm or have an adverse effect on a patient. A ‘control’ is a measure put in place to reduce the risk of a hazard occurring. The investigation focused on: Equipment controls that enable effective delivery of medication. Environmental and staff factors that can influence the monitoring of medication delivery via ambulatory infusion pumps. Findings Current ambulatory infusion pump alarms may not effectively notify staff of hazardous situations (situations where intervention by a healthcare professional is needed because there is potential for harm to a patient). Alarms may occur, but if staff are not alerted to them, the required interventions may not take place. Current national reporting systems are complicated and do not support the capture and sharing of medical device related incidents across appropriate national bodies. To enable the effective cross organisational sharing of incident data local incident reporting systems, which feed into the NHS England Learn from Patient Safety Events service, would need to meet the Medicines and Healthcare products Regulatory Agency (MHRA) data standards. The main factors that affect staff’s ability to hear an alarm and intervene in a hazardous situation are the infrastructure and working environment in which infusion pumps are used. When staff cannot hear or see an alarm, outside of the 4 hourly infusion pump staff checks, they are reliant on patients or families to alert them to issues with an ambulatory infusion pump. This is not always possible when the patient is unwell. International standards used by manufacturers of medical devices do not fully consider the environment in which the equipment is used. NHS staff are not always given guidance on how to use specific medical devices in the context of their varying environments, and how this may affect patient safety. The inability to access the Palliative Care Formulary (a best practice guide for medication prescribers), as a free resource, may have an impact on patient safety. This can be both in the palliative care specialism and across the wider healthcare system. Safety recommendations HSSIB recommends that the British Standards Institution engages with appropriate stakeholders to develop national human factors guidance, including consideration of usability and environment of use, for medical devices. This is to support international medical device standards and help manufacturers and healthcare staff to recognise these elements for the improvement of patient safety. HSSIB recommends that the British Standards Institution engages with international standards committees to influence the inclusion of human factors, including usability and environment of use requirements, in medical device and medical electrical equipment standards. HSSIB recommends that NHS England and the Medicines and Healthcare products Regulatory Agency work together to develop an effective mechanism for sharing medical device related incident data, including where devices function as designed. Safety observations Palliative care providers can improve patient safety by reviewing their ambulatory infusion pumps checks to determine whether they are in line with the Palliative Care Formulary guidance and the minimum expectations of NHS England. Ambulatory infusion pump manufacturers can improve patient safety by considering new technology to develop improved methods of alerting staff to hazardous situations. Care providers can improve patient safety for inpatients who are given medication using ambulatory infusion pumps by providing safety netting advice about alerting nursing staff to alarms, appropriate places to put ambulatory infusion pumps, and the consequences of patient interaction with the device.

Extravasation is the leakage of intravenously administered solution into surrounding tissues, which can cause serious damage to the patient. There are multiple guidelines and local policies relating to extravasation injuries but not a singular national uniform policy.  NHS Resolution share their recent slides on what can be learned from extravasation claims, presented at the IV Therapy Summit.

These videos posted by Melissa Sheldrick tell the story of her son Andrew, who died aged eight from a medication error. The investigation into Andrew's death found that he had been given baclofen by his pharmacy instead of the tryptophan he had been prescribed. When tested, the dose of baclofen in the bottle given to Andrew contained three times the lethal dose of baclofen for adults. PSMF Melissa's story. In this video, Andrew's mother Melissa talks about what happened to Andrew and how it led to her campaigning for mandatory reporting of medication errors by pharmacists across Canada, Australia and the US. Patients taking the lead: Collaborating for safer healthcare. This presentation was originally given at the World Health Organization's (WHO's) World Patient Safety Day conference on 12 September 2023 in Geneva, Switzerland. Melissa tells Andrew's story and talks about how she has raised awareness of gaps in accountability for pharmacies and pharmacists. She describes how she was invited to be part of a taskforce to improve safety in pharmacy by the pharmacy regulator in her home state of Ontario—this was the first time a member of the public had been included in such a taskforce.