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Found 30 results
  1. Gallery Image
    Noradrenaline and tranexamic acid.jpg
    Shared with hub by Dr Abigail Clark-Morgan: Images shared of our stocked noradrenaline ampules and tranexamic acid – these have been mixed up and we are looking to stock alternative volumes of noradrenaline to reduce the likelihood of confusion. The incident also highlighted the importance of checking all the ampules drawn up, drawing up your own medications at the point of administration and effective second checking. Part of our immediate response was to label the noradrenaline ampules to make them more obviously different (the purple ampules pictured below).

    © Healthcare UK

  2. Gallery Image
    Bupivacaine alongside sodium choloride.jpg
    Bupivacaine solution, a medication used to decrease feeling in a specific area, alongside sodium chloride used as a saline solution. What could go wrong?! Another example of almost identical packaging/labelling.
  3. News Article
    A French study of adverse drug reactions has a highlighted a link between drug shortages and medication error. Data from the French Pharmacovigilance Database show that medication errors were identified in 11% of the 462 cases mentioning a drug shortage. The researchers found that medication errors usually occurred at the administration step and involved a human factor. “A drug shortage may lead to a replacement of the unavailable product by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labelling, dosage and sometimes a differen
  4. Gallery Image
    Midazolam.jpg
    Shared from Twitter: What could go wrong? Same size, same colourings … Time for distinct and standardised size/colouring of paralytic agents?
  5. Content Article
    Saturday 17 September 2022 marks the fourth annual World Patient Safety Day. This event was established by World Health Organization (WHO) as a day to call for global solidarity and concerted action to improve patient safety. It aims to bring together patients, families, carers, healthcare professionals and policymakers to show their commitment to patient safety. Avoidable harm in health and social care What is patient safety? Simply put, patient safety is concerned with avoiding unintended harm to people during their care and treatment. WHO describes it as follows: “Patient safe
  6. Content Article
  7. Content Article
  8. Gallery Image
    Bupivacaine and sodium chloride
    Do we need a magnifying glass in every anaesthetic room? Only a matter of time until something bad happens...
  9. Gallery Image
    Sodium chloride and levobupivacaine
    Levobupivacaine is a local anaesthetic. Labelling very similar to the Sodium chloride.
  10. Gallery Image
    Solutions for injections
    Three very different solutions for injection - magnesium sulfate, water, sodium chloride - so why is the labelling so similar?
  11. Content Article
  12. Gallery Image
    Clobazam.jpg
  13. Gallery Image
    Sodium Cholride and Metronidazole.jpg
  14. Gallery Image
    Stexerol-D3.jpg
  15. Content Article
    During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities. An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit. In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution
  16. Content Article
  17. Content Article
    This issue (episode 3) focuses on: safe administration of concentrated insulin products errors with confusing product labelling educating patients about safe medication practices.
  18. Content Article
    This action plan includes details of the event, notable practice, improvements to be made and the learning found.
  19. Gallery Image
    Calcium Gluconate and Sodium Chloride solutions.jpg
  20. Gallery Image
    Aspirin.jpg
    A patient bought wrong aspirin from pharmacy and accidentally overdosed. Easily done with such similar packaging.
  21. Content Article
    There are currently 237 million medication errors every year. While the safety risks are small in most of these cases, for some patients there are serious risks because of errors in prescribing, dispensing or monitoring medications. NHS Digital’s newly published medications guidance aims to change this, by making sure that information about medicines can be shared digitally between systems in different care settings. This podcast talks about the real benefits this will bring, and how it will impact both clinicians and patients.
  22. Content Article
    This issue (episode 2) focuses on: the most common safety issues associated with measuring patient weight steps to eliminate drug concentration confusion understanding Patient Care Analgesia (PCA) by proxy.
  23. Gallery Image
    Medication - generic names.png
  24. Gallery Image
    Sodium Chloride and paracetamol solution.jpg
    These two solutions look very similar. One is paracetamol, the other Sodium Chloride. Example of packaging/labelling contributing to adverse events.
  25. Content Article
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