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Found 270 results
  1. Content Article
    Medication errors in ambulatory care settings present unique patient safety challenges. This systematic review explored the prevalence of medication errors in outpatient and ambulatory care settings. Findings indicate that prescribing errors (e.g., dosing errors) are the most common type of medication error and are often attributed to latent factors, such as knowledge gaps.
  2. Content Article
    Over the past decade, the implementation of simulation education in health care has increased exponentially. Simulation-based education allows learners to practice patient care in a controlled, psychologically safe environment without the risk of harming a patient. Facilitators may identify medical errors during instruction, aiding in developing targeted education programs leading to improved patient safety. However, medical errors that occur during simulated health care may not be reported broadly in the simulation literature. This study in the Journal of Patient Safety aimed to identify and categorise the type and frequency of reported medical errors in healthcare simulation.
  3. Content Article
    Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. In the article 'Truth and compassion' (page 20-21), David Alderson considers the patient’s perspective on mistakes.
  4. Content Article
    Children are more than twice as likely as adults to experience a medication error at home. In this interview for the journal Patient Safety, Dr Kathleen Walsh, paediatrician at Boston Children’s Hospital, discusses why that is the case and provides some tips to keep children—and adults—safe.
  5. Content Article
    SHOT is the UK’s independent, professionally-led haemovigilance scheme. It collects and analyses anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. This document contains updated information on reporting categories and what to report to the scheme.
  6. Content Article
    Traditionally, recommendations regarding responding to medical errors focused mostly on whether to disclose mistakes to patients. Over time, empirical research, ethical analyses and stakeholder engagement began to inform expectations — which are now embodied in communication and resolution programmes (CRPs) — for how healthcare professionals and organisations should respond not just to errors but any time patients have been harmed by medical care (adverse events). CRPs require several steps: quickly detecting adverse events, communicating openly and empathetically with patients and families about the event, apologising and taking responsibility for errors, analysing events and redesigning processes to prevent recurrences, supporting patients and clinicians, and proactively working with patients toward reconciliation. In this modern ethical paradigm, any time harm occurs, clinicians and health care organisations are accountable for minimising suffering and promoting learning. However, implementing this ethical paradigm is challenging, especially when the harm was due to an error.
  7. Content Article
    Interprofessional communication is of extraordinary importance for patient safety. To improve interprofessional communication, joint training of the different healthcare professions is required in order to achieve the goal of effective teamwork and interprofessional care. The aim of this pilot study from Heier et al. published in BMC Medical Education was to develop and evaluate a joint training concept for nursing trainees and medical students in Germany to improve medication error communication.
  8. Content Article
    The US Food and Drug Administration (FDA) list of drug names with recommended tall man (mixed case) letters was initiated in 2001 with the agency’s Name Differentiation Project. Tall man lettering (TML) is a technique that uses uppercase lettering to help differentiate look-alike drug names. Starting on the left side of a drug name, TML highlights the differences between similar drug names by capitalizing dissimilar letters (e.g., vinBLAStine versus vinCRIStine and CISplatin versus CARBOplatin). TML can be used along with colour or bolding to draw attention to the dissimilarities between look-alike drug names, and alert healthcare providers that the drug name can be confused with another drug name. The Institute for Safe Medication Practices (ISMP) 'Look-alike drug names with recommended tall man (mixed case) letters' contains drug name pairs or larger groupings with recommended, bolded uppercase letters to help draw attention to the dissimilarities in look-alike drug names. The list includes mostly generic-generic drug names, although a few brand-brand or brand-generic names are included.  See also our Medication error traps gallery
  9. Content Article
    The relationship between management and the workforce, in very simplistic terms, can be considered one of reward in return for effort. The contracted effort is communicated through a roster. In organisations that have a continuous operation, blocks of effort are distributed to maintain the flow of output. The organisation of effort, then, is a legitimate function of management.  Norman's previous blog looked at performance variability under normal conditions. In this blog, Norman looks at the impact of physiological states and how management’s organisation of effort degrades decision-making.
  10. Content Article
    The healthcare workplace is a high-stress environment. All stakeholders, including patients and providers, display evidence of that stress. High stress has several effects. Even acutely, stress can negatively affect cognitive function, worsening diagnostic acumen, decision-making, and problem-solving. It decreases helpfulness. As stress increases, it can progress to burnout and more severe mental health consequences, including depression and suicide. One of the consequences (and causes) of stress is incivility. Both patients and staff can manifest these unkind behaviours, which in turn have been shown to cause medical errors. The human cost of errors is enormous, reflected in thousands of lives impacted every year. The economic cost is also enormous, costing at least several billion dollars annually. The warrant for promoting kindness, therefore, is enormous. Kindness creates positive interpersonal connections, which, in turn, buffers stress and fosters resilience. Kindness, therefore, is not just a nice thing to do: it is critically important in the workplace. Ways to promote kindness, including leadership modelling positive behaviours as well as the deterrence of negative behaviours, are essential. A new approach using kindness media is described. It uplifts patients and staff, decreases irritation and stress, and increases happiness, calmness, and feeling connected to others.
  11. Content Article
    In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk.  In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look. 
  12. Content Article
    In this article, Stephen Shorrock, Chartered Ergonomist and human factors specialist, shares some some insights on the concept of ‘human error and the idea of ‘honest mistakes’. He outlines the problem with thinking of errors as ‘causing’ unwanted events such as accidents, arguing that this approach ignores all of the other relevant ‘causes’, especially in high-hazard, safety-critical systems,
  13. Content Article
    Stephen Shorrock looks at how we use deficit-based taxonomies when describing incidents in healthcare and why neutralised taxonomies may be more flexible and useful.
  14. News Article
    A locum responsible pharmacist has been issued a warning after a patient died when he dispensed the wrong strength of oxycodone during a staffing crunch, the regulator has revealed. Paresh Gordhanbhai Patel supplied 120mg rather than the prescribed 20mg of oxycodone hydrochloride to an “elderly” patient while working two locum shifts as responsible pharmacist at Crompton Pharmacy at Whitley House Surgery in Chelmsford. After taking one tablet, the patient died from an “accidental” oxycodone “overdose”, the General Pharmaceutical Council’s (GPhC) fitness-to-practise (FtP) committee heard at a hearing held on 11-13 September. Mr Patel admitted that he was “stressed and overtired” when he failed to notice a “discrepancy” between the prescribed strength of oxycodone and what he ordered and dispensed, The regulator heard that Mr Patel was “over-conscientious” and felt compelled “at a human level” to help out at the under-staffed pharmacy, despite the fact that it was “not safe to do so”, it added. Mr Patel admitted that his errors “amounted to misconduct” and conceded to the committee that his fitness to practise was “impaired” because he “breached one of the fundamental principles of the pharmacy profession.” The regulator heard that Mr Patel had “immediately” admitted his mistake to the pharmacy and did so again at the coroner’s inquest, where he also publicly apologised to the patient’s family. Read full story Source: Chemist and Druggist, 12 October 2023
  15. Content Article
    Medication errors are a leading cause of patient harm globally. WHO launched the Global Patient Safety Challenge: Medication Without Harm, with the objective of preventing severe medication related patient harm globally. This publication is one of the documents in the WHO Technical Series on “Medication Safety Solutions” that the WHO is publishing, to address important aspects pertaining to medication safety.
  16. News Article
    Doctors missed a man’s stroke which led him to suffer another one and go temporarily blind. The man said that the experience had changed him from ‘an outgoing social person, to a sheltered man living in fear that he is not being looked after competently’. The 75-year-old visited his GP in Darlington complaining of dizziness, light-headedness, and a numb foot. He had experienced a stroke and should have been immediately sent to hospital. But doctors missed the signs, diagnosed him with a ‘dropped foot’ and requested an urgent MRI scan. However, due to an administrative error the referral wasn’t made and the scan never happened. A month after visiting the GP, the man suffered a blinding headache and diminished vision. He saw an ophthalmologist who referred him to a specialist team. He had suffered another stroke. He also paid for a private scan which confirmed the first stroke happened a month earlier. Distressingly, the man lost vision in his right eye, which he was told could be permanent. Fortunately, his sight returned eight weeks later. His daughter, who described the experience as ‘horrendous’, complained to the Parliamentary and Health Service Ombudsman (PHSO) about her father’s care. The PHSO found that the initial symptoms were signs of a problem with nerve, spinal cord, or brain function. Doctors should have suspected a stroke and immediately sent him to hospital. If that had happened, the second stroke and sight loss would likely have been avoided. Ombudsman Rob Behrens said: “Having a stroke and then being told you could be permanently blind must have been incredibly frightening. The impact on the man, and his family who supported him through the ordeal, will have been deep and long-lasting. “Mistakes like these need to be recognised and acted upon so that they are not repeated.” Read full press release Read case file Source: PHSO, 4 October 2023
  17. Content Article
    Melissa Sheldrick is a Patient Safety Expert, Patient and Family Advisor at ISMP Canada and member of Patients for Patient Safety Canada. With a passion for improving medication safety for all, Melissa uses her unique perspective as a caregiver with lived experience to drive change and promote a culture of safety within the healthcare system. Her dedication to this work is inspired by her personal experience as a mother who lost her 8-year-old son Andrew to a medication error in 2016.  This is their story.
  18. 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.
  19. News Article
    Sharri Shaw walked out of the CVS on Vermont Avenue in South Los Angeles in 2019 believing she had a prescription for the pain reliever acetaminophen. Instead the bottle held a medicine to treat high blood pressure, a problem she did not have. Shaw began taking the pills, not learning of the mistake until six days later when a CVS employee arrived at her home, according to a lawsuit she filed last year. The employee told her not to take the tablets, the lawsuit said, before leaving the correct prescription at her door. The mistake, she said, left her stunned. Shaw’s experience is far from an isolated event. California pharmacies make an estimated 5 million errors every year, according to the state’s Board of Pharmacy. Officials at the regulatory board say they can only estimate the number of errors because pharmacies are not required to report them. Most of the mistakes that California officials have discovered, according to citations issued by the board and reviewed by The Times, occurred at chain pharmacies such as CVS and Walgreens, where a pharmacist may fill hundreds of prescriptions during a shift, while juggling other tasks such as giving vaccinations, calling doctors’ offices to confirm prescriptions and working the drive-through. Christopher Adkins, a pharmacist who worked at CVS, and then at Vons pharmacies until March, said that management policies at the big chains have resulted in understaffed stores and overworked staff. “At this point it’s completely unsafe,” he said. Read full story Source: Los Angeles Times, 5 September 2023
  20. Content Article
    In this article in the Irish Times, Niall discusses his book, Oops! Why Things Go Wrong, and  explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, and most importantly, what we can do about it. You can also listen to an interview with Niall on BBC Radio Ulster’s Talkback (Listen from 38 mins to 57 mins). Related reading on the hub: Oops! Why things go wrong – a blog by Niall Downey
  21. News Article
    Making data on medical interventions easier to collect and collate would increase the odds of spotting patterns of harm, according to the panel of a recent HSJ webinar When Baroness Julia Cumberlege was asked to review the avoidable harm caused by two medicines and one medical device, she encountered no shortage of data. “We found that the NHS is awash with data, but it’s very fractured,” says Baroness Cumberlege, who chaired the Independent Medicines and Medical Devices Safety Review and now co-chairs the All-Party Parliamentary Group which raises awareness of and support for its findings. And it is that fracturing that can make patterns of harm difficult to spot. The report concluded that many women and children experienced avoidable harm through use of the hormone pregnancy test Primodos, the epilepsy drug sodium valproate, and the medical device pelvic mesh – simply because it hadn’t been possible to connect the dots. “It’s very hard to collect things together and to get an overall picture. And one of the things that we felt very strongly about was that data should be collected once, but used often,” said Baroness Cumberlege at a recent HSJ webinar. Run in association with GS1 UK, the event brought together a panel to consider how better data might help address patient safety challenges such as problems with implants. “But the big problem was they couldn’t identify who had which implants. No doubt somebody somewhere had written this down with a fountain pen and then someone spilt the tea over it and the unique information was lost,” recalled Sir Terence Stephenson , now Nuffield professor of child health at Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England. The review he chaired therefore suggested establishing a concept of person, product place – “for everybody who had something implanted in them, we should have their name, the identifier of what had been put in, and where it had been put in. And one of my panel members said: ‘Well, how are we going to record this? We don’t want the fountain pen and the teacup.’” Ultimately the answer suggested was barcode scanning. By scanning the wristband of a patient, that on the product being implanted, and one for the hospital theatre or department at which it was being implanted, the idea was to create an immediate and easy-to-create record. For those long convinced of the virtues of barcode scanning in health, it is a welcome development Two years later, the then Department of Health launched the Scan4Safety programme, in which six “demonstrator sites” implemented the use of scanning across the patient journey. At these organisations, barcodes produced to GS1 standards – meaning they are globally unique – are present on patient wristbands; on equipment used for care, including implantable medical devices; in locations; and sometimes on staff badges. Link to full article here (paywalled)
  22. Content Article
    It has become fashionable to purge the term ‘error’ from the safety narrative. Instead, we would rather talk about the ‘stuff that goes right’. Unfortunately, this view overlooks the fact that we depend on errors to get things right in the first place. We need to distinguish between an error as an outcome and error as feedback, writes Norman MacLeod in this blog for the hub.
  23. News Article
    RaDonda Vaught was sentenced to three years of supervised probation on the 13 May for a fatal medication error she made in 2017 while working as a nurse at the Vanderbilt University Medical Center in the USA. In remarks made during the sentencing hearing, Ms. Vaught expressed concerns over what her case means for clinicians and patient safety reporting. "This sentencing is bound to have an effect on how [nurses] proceed both in reporting medical errors, medication errors, raising concerns if they see something they feel needs to be brought to someone's attention," she said. "I worry this is going to have a deep impact on patient safety." Numerous medical organisations expressed similar concerns in statements circulated after Ms. Vaught's sentencing. "To achieve our goal of zero patient harm and death from preventable medical errors, we need to foster a culture where leadership of hospitals and healthcare organizations support healthcare workers and encourage them to share near misses," the Patient Safety Movement Foundation said in a statement. "Healthcare workers are human and healthcare systems need to ensure there are appropriate processes in place to provide their staff with a safe and reliable working environment so they can provide their patients with the best care. Only by identifying potential problems and learning from them can change occur." Read full story Source: Becker's Hospital Review, 16 May 2022
  24. News Article
    On 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers." "The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state." Read full statement Source: Washington State Nurses Association, 8 April 2022
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