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Found 166 results
  1. Content Article
    Harm due to medicines and therapeutic options accounts for nearly 50% of preventable harm in medical care. This World Health Organization (WHO) policy brief is a resource for policy-makers, health workers, healthcare leaders, academic institutions and other relevant institutions to help understand the global burden of medication errors, address and prevent medication-related harm at all levels of healthcare, aligned with the strategic plan of the third WHO Global Patient Safety Challenge: Medication Without Harm. 
  2. Content Article
    Peripheral nerve blocks (PNB) are safe and effective alternatives or supplements to general anaesthesia. They may improve pain control both during and after surgery, thus avoiding many of the side effects of systemic opioids. PNBs may also lead to improved patient satisfaction, decreased resource utilization, and may be better for the environment by decreasing usage of aesthetic gases and other medications. With the growing use of peripheral nerve blocks in the United States, this paper examines safety issues surrounding the procedures. It examines the safety of nerve blocks as it relates to: nerve injury recognition and treatment of local anaesthetic systemic toxicity (LAST) appropriate health care professional performance of timeouts to avoid wrong-site blocks.
  3. Content Article
    Ashleigh Hughes is a Senior Sister at an NHS chemotherapy day unit. In this interview she shares her personal story about the impact of antibiotic underdosing on her Mum’s end of life care. Antibiotic underdosing is a medication safety issue that has profound implications for the health service as well as individual patients, but there is currently a lack of understanding and recognition of the issue.
  4. Content Article
    Antibiotic underdosing is a widespread issue in the healthcare system. The use of modern infusion pumps to deliver intravenous (IV) medications has resulted in the practice of flushing IV lines being lost in some specialties. Failure to give full doses of IV antibiotics poses significant risks to individual patients as well as adding to the problem of antimicrobial resistance (AMR). In this interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT. A transcript is available below the video.
  5. Content Article
    This study aimed to assess whether the risk of 90-day mortality is comparable for individuals who switch early to oral antibiotics and those who continue intravenous (IV) antibiotics in the treatment of uncomplicated gram-negative bacteremia. The results suggest that transition to oral antibiotics within four days after initial blood culture may be an effective alternative to prolonged IV antibiotic treatment for uncomplicated gram-negative bacteremia.
  6. News Article
    The EU is to stockpile key medicines that will worsen the record drug shortages in the UK, with experts warning that the country could be left “behind in the queue”. The EU is seeking to safeguard its supplies by switching to a system in which its 27 members work together to secure reliable supplies of 200 commonly used medications, such as antibiotics, painkillers and vaccines. But the bloc’s move to insulate itself from growing drug shortages threatens to exacerbate the increasing scarcity of medicines facing the NHS, posing serious problems for doctors. “Europe is securing access to key drugs and vaccines as a single region, with huge influence and buying power. As a result of Brexit the UK is now isolated from this system, so our drug supplies could be at risk in the future,” said Dr Andrew Hill, an expert on the pharmaceutical trade. Britain is experiencing a record level of drug shortages, with more than 100 – including treatments for cancer, type 2 diabetes and motor neurone disease – scarce or impossible to obtain. Mark Dayan, the Brexit programme lead at the Nuffield Trust health thinktank, said the EU’s decision to act as a buying cartel could seriously disadvantage Britain. “There is a real risk that measures in such a large neighbour, which is now a separate market due to Brexit, will leave the UK behind in the queue when shortages strike,” Dayan said. It also has an initiative for member states to transfer stocks of medicine to cover shortages in others. These measures could shut UK purchasers out in certain scenarios. “This would risk worsening shortages from a starting point where they are already exceptionally severe for the UK and other countries, with a mounting impact in terms of costs and wasted time for the NHS, and in terms of patients struggling to get what their doctors have said they need.” Read full story Source: The Guardian, 25 January 2024 Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy or in hospital? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our hub community thread on the topic here or drop a comment below. You'll need to register with the hub first, its free and easy to do.
  7. Content Article
    Connections are critical junctures and points of access along intravenous (IV) lines. Microorganisms may colonise these connections, potentially leading to catheter-related bloodstream infections (CRBSIs). For patients, CRBSIs are a significant cause of morbidity and death, and for healthcare facilities these infectious complications lead to unnecessary costs. Safe connections may help reduce the risk of needlestick injuries for healthcare professionals (HCPs) and the occurrence of CRBSIs for patients. In this webinar recording, Nancy Trick, Registered Nurse and Adjunct Instructor at Perdue Global University in West Lafayette, USA, discusses CRBSIs and presents solutions to help prevent them. After watching this webinar, you should be able to: describe open versus closed infusion systems in VAM. briefly discuss the clinical risks of open infusion systems. discuss clinical practice change. consider how evidence-based standards of practice recommend using closed IV access/needleless connectors.
  8. Content Article
    The Parkinson’s Excellence Network has launched three new practical guides to support UK health professionals to deliver time critical Parkinson’s medication on time in hospital.
  9. Content Article
    The objective of this systematic review from Benhamou et al. was to assess the clinical, economic, and health resource utilisation outcomes associated with the use of prefilled syringes in medication administration compared with traditional preparation methods. The findings provide new insights into clinical and economic benefits of prefilled syringe adoption. These benefits include improved medication delivery and safety, which can lead to time and cost reductions for health care departments, hospitals, and health systems. However, further real-world research on clinical and economic outcomes, especially in contamination, is needed to better understand the benefits of prefilled syringes.
  10. Event
    This conference focuses on improving practice and patient safety to reduce extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce extravasation injury. Learn from outstanding practice in recognizing, treating and escalating extravasation injury. Reflect on national developments and learning. Ensure vesicants are administered in the safest way. Develop your skills in training frontline staff to recognise evolving injuries. Understand how you can implement preventative measures. Identify key strategies for improvement. Educate patients to raise alarm and improve consent procedures. Develop protocols to support practice. Understand the role and competencies of the NHS trust lead for extravasation. Ensure effective treatment, and early intervention in severe wounds. Learn from case studies in cancer, maternity, radiology and paediatrics. Ensure you are up to date with the latest legal cases. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/iv-therapy-summit-2023 or email kerry@hc-uk.org.uk Follow on Twitter @HCUK_Clare #IVTherapy hub members receive a 20% discount. Email info@pslhub.org for discount code.
  11. Content Article
    On 11 January 2021 an investigation into the death of Susan Ann Gladstone was started. The investigation concluded at the end of the inquest on 20 November 2023. The conclusion of the inquest was Susan died as a result of a generally unknown interaction between warfarin and tramadol which caused exceptional thinning of her blood: 1a Intraparenchymal and subarachnoid haemorrhage.
  12. News Article
    NHS England has been told it must take action to raise awareness about the potentially fatal interaction between tramadol and warfarin, following the death of a patient. Graham Danbury, assistant coroner for Hertfordshire, issued a prevention of future deaths report on 1 December 2023, after Susan Gladstone, from Hertfordshire, died on 8 January 2021 from a bleed in the brain. An inquest, which ended on 20 November 2023, concluded that Gladstone “died as a result of a generally unknown interaction between warfarin and tramadol, which caused exceptional thinning of her blood”. Gladstone was prescribed tramadol twice for lower back pain: on 20 December 2020 and 4 January 2021. According to the report, she had been taking the anticoagulation medication warfarin for “a number of years”. The report continues: “There was nothing to warn the prescribing doctor of any possible interaction. I found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event, fatal INR to develop. “In my opinion, actions should be taken to prevent future deaths and I believe you, NHS England, have the power to take such action.” Read full story Source: Pharmaceutical Journal, 13 December 2023
  13. News Article
    An "evil" nurse who drugged patients on a stroke unit for an "easy shift" and a healthcare worker who conspired with her have been jailed. Catherine Hudson, 54, was found guilty of giving unprescribed sedatives to two patients at Blackpool Victoria Hospital in 2017 and 2018. She was also convicted of conspiring with Charlotte Wilmot, 48, to give a sedative to a third patient. Hudson was jailed for seven years and two months. Wilmot was sentenced to three years. Evidence during the trial highlighted the "dysfunctional" drugs regime on the stroke ward with free and easy access to controlled drugs and medication which led to "wholesale theft" by staff. Prosecutors described it as a "culture of abuse" after police examined WhatsApp phone messages between the co-defendants and other members of staff. The pair were investigated after a student nurse witnessed events while on a work placement on the stroke unit and told senior managers in November 2018, who called in police. The whistleblowing nurse, who the prosecution had asked not to be named, told officers she had concerns over the use of insomnia medication Zopiclone, which can be life-threatening if given inappropriately. She said Hudson had told her the patient had a Do Not Resuscitate Order in place "so she wouldn't be opened up if she died or... came to any harm". Read full story Source: BBC News, 14 December 2023
  14. News Article
    An overworked nurse who failed to give medication to a patient told a colleague “I don’t care anymore”, a hearing was told. Niall O’loingsigh was lead nurse in the Avon unit within the Charterhouse Care Home in Keynsham, Somerset, which looks after elderly residents and those with dementia. In 2020 a complaint was made by a colleague about him breaching safe medication management protocols and being dishonest in relation to medication administration. A misconduct hearing at the Nursing and Midwifery Council was told later, in May 2021, he was seen behaving in an “unsupportive manner” and told a colleague: “I don’t care anymore”. The panel also heard how on 18 May 2021, Mr O’loingsigh failed to record he had administered medication to three residents, BristolLive reported. A colleague wanted to report Mr O’loingsigh’s conduct, in which Mr O’loingsigh patted her on the back and said “well done mate, you did the right thing but I may lose my PIN though”. Mr O’loingsigh told his colleague of feelings of distress and anxiety about being reported and its impact on his career, but he wanted to reassure her. The colleague however felt “uncomfortable”. The panel found that he underwent “a course of conduct which put patients at risk of suffering harm at the time of the incidents” and noted “there were repeated failures over a period of time”. Read full story Source The Mirror, 10 December 2023
  15. News Article
    The under delivery of intravenous antibiotics in some NHS hospitals due to lack of polices and compliance may be contributing to antimicrobial resistance (AMR), according to a parliamentary report. Findings in the report indicated that many health service organisations do not have policies in place to reduce the risk of under delivery and those that do can struggle to comply fully with them. The report’s authors warned that the residual volume of antibiotic remaining in the line of the IV administration set can result in under delivery of up to 30% of the prescribed dose. They said that, as a result, this could be leading to possible resistance within patients, owing to the accumulative effect. Nurses involved with compiling the document have called for action. Based on the findings, the report recommended that all NHS organisations implement line flushing policies by late 2024, with support from the Department for Health and Social Care. Read full story (paywalled) Source: Nursing Times, 9 December 2023 Further reading on the hub: 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
  16. Content Article
    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.
  17. Content Article
    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.
  18. Content Article
    As clinicians, our primary objective is to provide the best possible care to our patients. In this pursuit, the administration of short-term intermittent IV antibiotics plays a crucial role in combating infections and saving lives; however, there is an under recognised issue, under delivery, that results in the misuse of antibiotics and could be exacerbating antimicrobial resistance. In this blog, Claire Davies, Clinical Therapy Manager at B. Braun Medical Ltd., explores the issue of under delivery and provides essential insights for clinicians to optimise their antibiotic therapy.
  19. Content Article
    As a patient receiving treatment for a bacterial infection through an IV administration set, commonly referred to as a drip, it’s essential to know that antibiotics play a crucial role in helping you get better. In this blog, Claire Davies, Clinical Therapy Manager at B. Braun Medical Ltd., explores an under-recognised issue that can affect your treatment, the unintentional under delivery of antibiotics via your drip. Claire explains why it’s important to ensure that all of your prescribed antibiotic dose is delivered via your drip and the measures being taken by healthcare providers to ensure that this happens.
  20. Content Article
    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.
  21. Event
    This conference focuses on improving practice and patient safety to reduce Extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce Extravasation Injury Learn from outstanding practice in recognizing, treating and escalating extravasation injury Reflect on national developments and learning Ensure vesicants are administered in the safest way Develop your skills in training frontline staff to recognize evolving injuries Understand how you can implement preventative measures Identify key strategies for improvement Educate patients to raise alarm and improve consent procedures Develop protocols to support practice Understand the role and competencies of the NHS trust lead for extravasation Ensure effective treatment, and early intervention in severe wounds Learn from case studies in cancer, maternity, radiology and paediatrics Ensure you are up to date with the latest legal cases Self assess and reflect on your own practice Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  22. Content Article
    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.
  23. News Article
    Millions of people wrongly believe they are allergic to penicillin, which could mean they take longer to recover after an infection, pharmacists say. About four million people in the UK have the drug allergy on their medical record - but when tested, 90% of them are not allergic, research suggests. The Royal Pharmaceutical Society says many people confuse antibiotic side-effects with an allergic reaction. Common allergic symptoms include itchy skin, a raised rash and swelling. Nausea, breathlessness, coughing, diarrhoea and a runny nose are some of the others. But antibiotics, which treat bacterial infections, can themselves cause nausea or diarrhoea and the underlying infection can also lead to a rash. And this means people often mistakenly believe they are allergic to penicillin, which is in many good, common antibiotics. These are used to treat chest, skin and urinary tract infections - but if people are labelled allergic, they are given second-choice antibiotics, which can be less effective. Read full story Source: BBC News, 28 September 2023
  24. Content Article
    People with Parkinson’s need their medication on time every time. Yet over half of people with the condition don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death. Parkinson's UK are campaigning to make sure that no one with Parkinson’s is worried that they will leave hospital more unwell than when they went in.  Whether you have Parkinson’s, support someone who does, work in the health and care system or campaign to improve it, you can take action to make hospitals and care homes safer.  Together we can get more people to understand how big this problem is. And we can put pressure on the right people, across the UK, to change hospital policies, improve prescribing in hospitals and make sure staff are trained to give time critical medication.
  25. Content Article
    The Patient Safety Network (PSNet) produces primers which provide guidance on  key topics in patient safety through context, epidemiology and relevant PSNet content. This primer focuses on nurse-related medication administration errors and highlights that despite error reduction efforts through implementing new technologies and streamlining processes, medication administration errors remain prevalent. It covers the background to the issue, low-tech and high-tech prevention strategies and the current context.
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