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Showing results for tags 'Medication - related'.
Found 57 results
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Bupivacaine alongside sodium choloride.jpg
Patient Safety Learning posted a gallery image in Medication
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. -
News ArticlePhrases such as “cutting edge,” “game changing,” and “ground breaking” have no place in the description of new drugs by the government and NHS agencies, a therapeutics specialist and GP has warned. James Cave, editor in chief of the Drug and Therapeutics Bulletin (DTB), said in an editorial1 that the degree of hyperbole and omission of important information in government press releases and media statements “leaves patients and healthcare professionals with a limited and unbalanced view of a medicine.” In a letter to the heads of NHS England, the National Institute for Health and Care
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ISMP Canada Safety Bulletins
Patient Safety Learning posted an article in Medication
2022 ISSUE 1 - Anti-rejection medications: Analysis of reported errors ISSUE 2 - Mitigating Risk for Medication Errors Involving Paxlovid ISSUE 3- Heightened Risk of Methotrexate Toxicity in End-Stage Renal Disease ISSUE 4 - ALERT: Multipronged Strategy Required to Manage Shortage of Sterile Water for Injection ISSUE 5 - Pediatric Medication Errors in the Community: A Multi-Incident Analysis ISSUE 6 - ALERT: Substitution Error with Tranexamic Acid during Spinal Anesthesia ISSUE 7 - Emergency Care Plans Can Save Lives ISSUE 8 - ALERT: Infusion Errors Lead -
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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 -
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Content ArticleKey messages As many as one in ten hospitalisations in OECD countries may be caused by medication related harm. One in five inpatients experience medication-related harms during hospitalisation. Over $54 billion (US Dollars) is spent on medication-related harm in OECD countries (cost from avoidable admissions due to medication related harms plus added length of stay due to preventable hospital-acquired medication-related harms). This report is divided into four main sections: 1. Medication-related harms and errors are not rare events and have significant econ
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Content ArticleThese four vlogs are edited versions of vlogs originally commissioned by the NHS. They are all fully referenced based on UK National Institute for Health and Care Excellence (NICE) guidelines and on the Royal Pharmaceutical Society Prescribing Competency Framework for all prescribers (see the video description) and contain links to useful sources of further information. Shared decision making - 'It's my decision', which covers the latest NICE Guideline on shared decision making. 'Too much information' - Dealing with information overload on medicines & prescribing, which inclu
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Content ArticleThe mission of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is to maximise the safe use of medications and to increase awareness of medication errors through open communication, increased reporting and promotion of medication error prevention strategies. Goals Stimulate the development and use of reporting and evaluation systems by individual health care organisations. Stimulate reporting to a national system for review, analysis, and development of recommendations to reduce and ultimately prevent medication errors. Examine
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World Patient Safety Day webinar hosted by COHSASA, AfiHQSA and C-Care
Patient-Safety-Learning posted a calendar event in Community Calendar
To mark the annual World Patient Safety Day, three organisations - COHSASA of South Africa, AfiHQSA of Ghana and C-CARE (IHK) of Uganda - are collaborating to bring you the latest thinking across Africa regarding 'Medication without harm', the theme for WHO's Third Global Patient Safety Challenge. The Challenge aims to reduce the global burden of iatrogenic medication-related harm by 50% within five years. Join us to hear new ideas, visions and solutions to address medication-related adverse events which cause untold death and suffering around the world. Register for the meeting -
Content ArticleDid you know? Key causes of anti-infective medication error claims: Failure to check allergy status. Failure to cross-check the ingredients of a medication against allergy status. Failure to adjust dose of medication to the patient’s weight. Failure to adjust dose of medication according to renal function. What can you do? When prescribing antibiotics, refer to the British National Formulary (BNF) for guidance on adjusting dosages according to patient weight, kidney function and the frequency of monitoring. Refer to the traffc light system for
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News ArticleOnly a quarter of patients on valproate, who do not have appropriate contraception, are being referred by their pharmacist to their GP or a specialist about the issue, an audit carried out by NHS England has found. A report on the 2019/2020 Pharmacy Quality Scheme Valproate Audit — which was carried out in community pharmacies across England — published on 11 August 2022, has indicated that the Medicines and Healthcare products Regulatory Agency’s (MHRA’s) safety requirements for use of valproate in women and girls of childbearing age, and trans men who are biologically able to be pregnan
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Storage and labelling
Patient Safety Learning posted a gallery image in Miscellaneous
Similar looking boxes, but different drugs, stored together on the shelf. Easy to pick the wrong one up. -
Content ArticleArterial lines are routinely fitted for severely ill patients in critical care and are flushed with a solution to maintain patency, and ensure that blood does not clot in the line. Saline is recommended as the flush solution for arterial lines. There is a known patient safety risk in connection with this where glucose solutions being inadvertently and incorrectly used to flush arterial lines. This has led to inaccuracies in blood glucose measurements, which resulted in unnecessary administration of insulin and subsequent cases of hypoglycaemia, some of which have been fatal. Findings
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News ArticleA shortage of some medicines is putting patients at risk, pharmacists have warned. A poll of 1,562 UK pharmacists for the Pharmaceutical Journal found more than half (54%) believed patients had been put at risk in the past six months due to shortages. A number of patients have been facing difficulties accessing some medicines in recent months, sometimes having to go to multiple pharmacies to find their prescription or needing to go back to their GP to be prescribed an alternative. Since June, the government has issued a number of "medicine supply notifications", which highlight
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Content ArticleADRe is designed for use by nursing staff (NVQ level 3-5 or above), the professionals closest to patients. By using ADRe complex information on drugs is combined into a checklist providing advice on common problems. This helps nurses recognise and act on adverse drug reaction, including pain, dental pain, aggression, peptic ulcers, and sedation. In doing so, it greatly enhances the administration of medicines, and by capturing this individualised picture of the patients’ health and well-being prompts prescribers to refine dosages. ADRe is very simple to use: Nurses use the Profile
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Content ArticleKey recommendations Democratising access Governments should: Fund annual medicine reviews to help people with chronic conditions with decision making and any identified gaps in care, and report on the number of medicine reviews conducted every year across different demographic groups. Prevent co-payments from causing a barrier to adherence, as evidence shows they can hinder people from taking prescribed medication. Invest in HCP training programmes on behaviour change to supply workers with the requisite skills and knowledge to support adherence to medication regim
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US doctor accused of killing 14 patients found not guilty
Patient Safety Learning posted a news article in News
In an unprecedented murder case in the United States about end-of-life care, a physician accused of killing 14 critically ill patients with opioid overdoses in a Columbus, Ohio hospital ICU over a period of 4 years was found not guilty by a jury Wednesday. The jury, after a 7-week trial featuring more than 50 witnesses in the Franklin County Court of Common Pleas, declared William Huse not guilty on 14 counts of murder and attempted murder. In a news conference after the verdict was announced, lead defense attorney Jose Baez said Husel, whom he called a "great doctor," hopes to pract
