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Found 33 results
  1. Gallery Image
    Fentanyl, a synthetic opioid, and naloxone, a medication used to reverse or reduce the effects of opioids, both in very similar bottles and packaging. Shared originally on Twitter by @sassistheword
  2. Gallery Image
    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

  3. Gallery Image
    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.
  4. 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
  5. Gallery Image
    Shared from Twitter: What could go wrong? Same size, same colourings … Time for distinct and standardised size/colouring of paralytic agents?
  6. 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
  7. Gallery Image
    Do we need a magnifying glass in every anaesthetic room? Only a matter of time until something bad happens...
  8. Gallery Image
    Levobupivacaine is a local anaesthetic. Labelling very similar to the Sodium chloride.
  9. Gallery Image
    Three very different solutions for injection - magnesium sulfate, water, sodium chloride - so why is the labelling so similar?
  10. Gallery Image
    These two solutions look very similar. One is paracetamol, the other Sodium Chloride. Example of packaging/labelling contributing to adverse events.
  11. Gallery Image
    A patient bought wrong aspirin from pharmacy and accidentally overdosed. Easily done with such similar packaging.
  12. Content Article
    To improve safety, it is absolutely essential that human factor and design principles are embedded into the specifications for devices and this is what NHS Supply Chain are aiming to achieve through focused engagement with the end users of the products to gain a full understanding around who what where how and when they are used.
  13. Content Article
    Newsletters May 2021 Contents: Editorial: 'A just restorative culture' (Wim van Wassenhove and Sidney Dekker) 'What is at stake for the ego, what are the risks for the patients?' (Anne Rocher) 'The mental rehearsal used by fighter pilots' (Pascal Berriot) 'Basic ergonomics, or how to make your life easier' (Guillaume Tirtiaux) Other topics: fatigue and decision making processes, new devices and reflex actions, preoccupation during surgical procedures. January 2021 Contents: Editorial: 'Feedback : doing systemic analysis without clouding th
  14. Event
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    Patient Safety: Embracing technology in a rapidly evolving healthcare environment to reduce medication errors. In England 237 million mistakes occur at some point in the medication process. By embracing technology that already exists, we may actually hold the key to being able to significantly reduce this figure. Join Andrea Jenkyns MP, pharmacy and nursing thought leaders and patient safety representatives for an interactive discussion on embracing technology to reduce medication errors. The timing of this event is particularly significant as World Patient Safety Day takes place the
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