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Found 67 results
  1. News Article
    The ban on giving puberty blockers to under-18s questioning their gender identify is to be made permanent, Health Secretary Wes Streeting has announced. Streeting told MPs he was making the temporary ban introduced in May indefinite across the UK, following a consultation and advice from the Commission on Human Medicines - calling the way the drugs had been used a "scandal". The expert group said prescribing the drugs to children for gender dysphoria was an "unacceptable safety risk". Campaigners on both sides have reacted to the news, with those in support of the ban commending Streeting's "integrity" and those against calling it "discrimination". A temporary ban was put in place by the last Conservative government, and had been renewed twice by Streeting. He said on Monday that the review identified cases where children had been prescribed the treatment after filling out an online form and only having one online consultation with a healthcare provider. The health secretary said it was essential for the government to be evidence-led when it came to healthcare. Read full story Source: BBC News, 11 December 2024
  2. Community Post
    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  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. Gallery Image
    Similar looking boxes, but different drugs, stored together on the shelf. Easy to pick the wrong one up.
  5. Content Article
    This YouTube playlist containing 12 short vlogs (each lasting 10 minutes or less) is a cut-down version of Continuing Professional Development work commissioned by the NHS in England. These are part of our patient led clinical education work and involved working with patients, carers, and relatives as equals to produce the videos. These vlogs are based on the (UK) Royal Pharmaceutical Society Competency Framework for all Prescribers, and related guidelines from professional bodies in the UK. They are designed for clinicians (across all disciplines and specialities), patients, carers, parents, relatives and the public.  The short videos focus on providing refresher information, updates on hot topics and materials that can be used for reflection both individually and within clinical teams.  They cover: Shared decision making Information mastery Interpretation of numerical data Root causes on medicines and prescribing errors Taking a history Basic pharmacology Risk areas and red flags Ethics, the law and prescribing Deprescribing Remote prescribing Prescribing for frailty and multimorbidity Prescription writing and safe prescribing The original materials were accompanied by live sessions, questions for reflection (some of which are included here), separate refresher questions, detailed prescribing scenarios, and competency assessments.  
  6. News Article
    The Centers for Disease Control and Prevention alerted doctors nationwide Monday about a limited availability of certain doses of a newly approved antibody drug given to infants to prevent RSV infection. Cases of RSV, or respiratory syncytial virus, have started to rise as cold and flu season begins. "RSV season is here," said Dr. Buddy Creech, a pediatric infectious disease doctor at Vanderbilt University Medical Center in Nashville, Tennessee. "We are seeing a substantial increase in the amount of RSV such that in many areas, it has become the most commonly identified respiratory virus causing disease in children. "This is one of the reasons why there's probably a lot of scrambling going on," he said, "to identify those babies at highest risk and to try to prioritize them, since it's such a limited resource right now." Read full story Source: NBC News, 23 October 2023
  7. News Article
    Two healthcare workers who exchanged vile texts while needless drugging sick people to ‘keep them quiet’ have been found guilty of ill-treating patients. Senior nurse Catherine Hudson, 54, was found to have regularly tranquillised patients unnecessarily for her own amusement and to have an ‘easy’ shift. While Charlotte Wilmot, 48, an assistant practitioner, wrote vile texts encouraging her to carry out the dangerous acts, with complete disregard for the consequences. Preston Crown Court heard the pair worked on the stroke unit at Blackpool Victoria Hospital and had carried out needless sedations between 2017 and 2018. Restrictions on prescription drugs were so lax in the stroke unit that staff would help themselves and self-medicate or steal drugs to supply to others, the court heard. Drugs such as Zopiclone, a powerful medicine used to treat insomnia, were often stolen and used to drug multiple patients. Police launched an investigation in November 2018 after a student nurse raised concerns about the treatment of patients in the stroke unit. A number of staff members were arrested during the course of the investigation and their mobile devices were seized. Read full story Source: The Independent, 6 October 2023
  8. News Article
    A group of potent synthetic opioids called nitazenes have been linked to a rise in overdoses and deaths in people who use drugs, primarily heroin, in England over the past two months, drug regulators have warned. The Office for Health Improvements and Disparities has issued a National Patient Safety Alert on potent synthetic opioids implicated in heroin overdoses and deaths. In the past 8 weeks there has been an elevated number of overdoses (with some deaths) in people who use drugs, primarily heroin, in many parts of the country (reports are geographically widespread, with most regions affected but only a few cities or towns in each region). Testing in some of these cases has found nitazenes, a group of potent synthetic opioids. Nitazenes have been identified previously in this country, but their use has been more common in the USA. Their potency and toxicity are uncertain but perhaps similar to, or more than fentanyl, which is about 100x morphine. The National Patient Safety Alert provides further background and clinical information and actions for providers.
  9. News Article
    Coroners have raised multiple warnings about the way a commonly-used medication is being prescribed to at-risk patients, HSJ has found. HSJ has identified at least nine ‘prevention of future deaths’ reports issued by coroners since 2017 which highlighted the way the deceased’s prescription for sertraline was handled, with two of these issued since the start of 2023. It comes as Open Prescribing data suggests sertraline prescriptions have increased by almost 40 per cent since 2019, which has led to concerns that GPs are struggling to meet the growing demand for follow-up checks. Read full story Source: HSJ, 9 August 2023
  10. News Article
    About one in seven people in the UK now take medication to treat depression but some say they are not being given appropriate advice about the potential side-effects of the drugs they have been prescribed. Seonaid Stallan's son Dylan was a teenager when he began receiving treatment for body dysmorphia and depression. "He was struggling with the way he felt about himself, the way he looked," Seonaid said. "He was extremely anxious. He would be physically sick. He would be unable to leave the house." Dylan, from Glasgow, was treated with the antidepressant Fluoxetine from the age of 16. But when he turned 18, his medication was changed to Sertraline. Within two months of his prescription change he had taken his own life. Read full story Source: BBC, 9 August 2023
  11. Content Article
    Since the 1990s, the prescribing of strong pain medicines called opioids has increased in England and most high-income countries. Oxford researchers review the global and national use of opioids and have developed tools to improve patient safety. The core areas of research and their outputs are highlighted in this article published by the Centre for Evidence Based Medicine.
  12. Content Article
    On Saturday 17 September 2022, the fourth annual World Patient Safety Day took place, established as a day to call for global solidarity and concerted action to improve patient safety. Medication safety was chosen as the focused for World Patient Safety Day 2022 due to the substantial burden of medication-related harm at all levels of care. In this report, the World Health Organization (WHO) provides an overview of activities in the countries that observed World Patient Safety Day 2022 to make this event. Surveying activity across 136 WHO member states that observed World Patient Safety Day 2022, the report details: Activities and events held by WHO headquarters, regional offices and country offices. National events, conferences and webinars held in different member states. Publications and videos highlight key issues relating to World Patient Safety Day, including a blog by Patient Safety Learning and a Patient Safety Spotlight Interview with Angela Carrington, Lead Pharmacist for Medication Safety In Northern Ireland. Involvement of patients and healthcare professionals in events and activities. Media coverage.
  13. Event
    until
    This virtual workshop will provide participants with background theory and hands-on practice in using a multi-incident analysis to analyse a group of medication incidents that share a common topic on day 1 and introduce a novel tool called the Medication Safety Culture Indicator Matrix (MedSCIM) on day 2. Register
  14. Event
    until
    This virtual workshop will provide participants with background theory and hands-on practice in using a multi-incident analysis to analyse a group of medication incidents that share a common topic on day 1 and introduce a novel tool called the Medication Safety Culture Indicator Matrix (MedSCIM) on day 2. Register
  15. Event
    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 FINAL INVITE FOR WPSD WEBINAR.pdf
  16. News Article
    Guy’s and St Thomas’ NHS Foundation Trust will work with Omnicell to develop a European technology-enabled inventory optimisation and intelligence service which will be initially implemented across South East London Integrated Care System (ICS). This partnership will encompass all six acute hospital sites within the South East London ICS, including Guy’s & St Thomas’, Kings College Hospital NHS Foundation Trust and Lewisham & Greenwich NHS Trust. The project will have the following goals: Develop analytics and reporting tools with a goal of improving patient safety, achieving increased operational efficiency and cost efficiencies Utilize the analytics and reporting tools with a goal of achieving agreed efficiencies and cost reductions Demonstrate the impact of managing clinical supplies and medicine spend together at scale Build a service model for the ICS which can be scaled up and adopted by other hospital groups in the UK Read the full article here
  17. News Article
    As part of wide-reaching work being carried out to review the methods and processes the National Institute for Health and Care Excellence (NICE) uses to develop guidance, the organisation has launched a public consultation on proposals for changing how it selects the topics it will develop guidance on. Covering guidance on medicines, medical devices and diagnostics, the proposals clarify the criteria which would see a device or diagnostic selected for NICE guidance development. In particular, these include where costs and impacts are expected to be significantly cost-incurring or cost-saving – or there is uncertainty around the likely cost or the impact it would have on the healthcare system. With regard to medicines, the new proposals would confirm the commitment made in the 2019 Voluntary Scheme for Branded Medicines Pricing and Access that pledged NICE would appraise all new active substances and significant licence extensions for existing medicines, except where there was a clear rationale not to do so. Similarly, all new or significantly modified interventional procedures that would protect patient safety will be selected if they are available to the NHS or independent sector, or set to be used outside of formal research. This proposed approach would move away from the 15 criteria currently used to select topics for evaluation by NICE’s Centre for Health Technology Evaluation and provide a clearer and simpler process. Helen Knight, Programme Director for Technology Appraisals and Highly Specialised Technologies at NICE, said: “Topic selection plays an important role in the development of NICE guidance and is designed to ensure that the guidance we produce is on topics that support healthcare professionals and others to provide care of the best possible quality. “These proposals will ensure we can continue to meet these ambitions at a time of unprecedented change in the healthcare system.” The consultation on the proposals runs until 19 November. This will be followed by a separate public consultation on the case for change to its processes in February and March 2021. Read full story Source: NHE, 12 October 2020
  18. News Article
    NHS Payouts linked to medication blunders have doubled in six years, fuelling record spending, official figures show. The NHS figures show that in 2019/20, the health service spent £24.3 million on negligence claims relating to medication errors - up from £12.8 million in 2013/14. The statistics show that in the past 15 years, almost £220 million has been spent on claims relating to the blunders. Previous research has suggested that medication errors may be killing up to 22,000 patients in England every year. Errors occur when patients are given the wrong drugs, doses which are too high or low, or medicines which cause dangerous reactions. In some cases, patients have been given medication which was intended for another person entirely, sometimes with fatal consequences. Other studies suggest that 1 in 12 prescriptions dispensed by the NHS involve a mistake in medication, dose or length of course. In some cases, patients have died after being given a dose of morphine ten times that which should have been administered, with other fatalities involving fatal reactions. Confusion often occurs when drugs are not labelled clearly, or when packaging of different medications looks similar. Jeremy Hunt, now chairman of the Commons Health and Social Care Committee, said the NHS needed to make far more progress preventing harms, instead of seeing an ever increasing negligence bill. He said: “It is nothing short of immoral that we often spend more cleaning up the mess of numerous tragedies in the courts, than we actually do on the doctors and nurses who could prevent them." Read full story (paywalled) Source: The Telegraph, 3 October 2020
  19. News Article
    Antibiotic resistance is an increasing challenge for modern medicine as more naturally occurring antimicrobials are needed to tackle infections capable of resisting treatments currently in use. New research from the University of Warwick has investigated natural remedies to fill the gap in the antibiotic market, taking their cue from a 1,000-year-old text known as Bald's Leechbook. Read the full article here.
  20. News Article
    A trial has been launched in the UK to test whether ibuprofen can help with breathing difficulties in COVID-19 hospital patients. Scientists hope a modified form of the anti-inflammatory drug and painkiller will help to relieve respiratory problems in people who have more serious coronavirus symptoms but do not need intensive care unit treatment. Half the patients participating in the trial will be administered with the drug in addition to their usual care, while the other half will receive standard care to analyse the effectiveness of the treatment. Read full story Source: The Independent, 3 June 2020
  21. Content Article
    This book aims to teach the key principles of patient safety to a diverse audience: physicians, nurses, pharmacists, other healthcare providers, quality and safety professionals, risk managers, hospital administrators, and others. It is suitable for all levels of readers: from the senior physician trying to learn this new way of approaching his or her work, to the medical or nursing student, to the risk manager or hospital board member seeking to get more involved in institutional safety efforts. Understanding Patient Safety is divided into three main sections. In Section I, it describes the epidemiology of error, distinguishes safety from quality, discusses the key mental models that inform our modern understanding of the safety field, and summarises the policy environment for patient safety. In Section II, it reviews different error types, taking advantage of real cases to describe various kinds of mistakes and safety hazards, introduces new terminology, and discusses what we know about how errors happen and how they can be prevented. Although many prevention strategies will be touched on in Section II, more general issues regarding various strategies (from both individual institutional and broader policy perspectives) will be reviewed in Section III. After a concluding chapter, the Appendix includes a wide array of resources, from helpful Web sites to a patient safety glossary.
  22. Content Article
    AHRQ PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential for or resulted in patient harm. Cases from outpatient, ambulatory surgery, home health, long-term care, and rehabilitation settings are of particular interest. When a case is selected, the editorial team invites an expert author to write a commentary based on the case. Please note that case submitters do not receive any “authorship” because case submissions are anonymous. However, submitters of selected cases will receive a $300 honorarium. The AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety.  Case submission When submitting a case, the following information is required. Title (please provide an appropriate title for the case). Patient Description (describe the patient [as much as you would in a case summary] at the time of the event of interest) Nature of Error (the nature of the error and any relevant events or contributing factors) Impacts/Effects (describe the impact of the error on the patient and state whether the patient was harmed or required increased level of care, even if only temporarily) How Error was Recognised (if not noted above, describe how the error was recognized) Recommendations (describe your suggestions for how providers or systems might prevent similar errors from happening in the future) Responses to each of the above areas are limited to 250 words. Please note that submissions may be extensively edited for consistency with PSNet’s style, without changing important clinical details. Case selection criteria The editorial team reviews submitted cases regularly and judges cases using the following criteria: How interesting is the case from a medical error/patient safety standpoint? Is the case an important example of a common error, or is it unique but nevertheless raises some key issues of general interest? Does the case have sufficient clinical detail to inform practicing clinicians? Does the case have significant educational value? Does the case highlight important systems issues? If you are interested in submitted a case, please visit: https://psnet.ahrq.gov/webmm/submit-case. You may be contacted if further information is needed to judge your case submission.
  23. Content Article
    The General Medical Council (GMC) has updated their ethical guidance on Good practice in prescribing and managing medicines and devices. The guidance supports doctors to be able to prescribe safely for their patients, whatever the setting. It sets out the GMC standards for good practice when prescribing face to-face or remotely, when prescribing unlicensed medicines and for when patient care is shared with another doctor Key updates include: new advice for doctors to stop prescribing controlled drugs without access to patient records, except in emergencies. stronger advice on information sharing, making it clear that if a patient refuses consent to share information with other health professionals it may be unsafe to prescribe. alignment with our updated ‘Decision making and consent’ guidance, highlighting the importance of good two-way dialogue between patients and doctors in all settings. updated advice on treating patients based overseas to clarify doctors may need to register in the country where they are based, where the patient is based, and where prescribed medicines are to be dispensed.
  24. Content Article
    Medicines and prescribing are highly risky areas of health care. It is estimated that more than 200 million medication errors occur in NHS every year, and that avoidable adverse drug reactions (ADRs) cause 712 deaths per year, at a financial cost of at least £98.5 million every year.[1] Many medicines and prescribing issues have been highlighted in reports and investigations into patient deaths over the years, yet the issues around prescribing competency are yet to be fully addressed. It is time this omission was rectified. This blog explains why I believe patients, the public and healthcare practitioners, need to be aware of the Prescribing Competency Framework.[2] It outlines why the framework must be applied in practice, used in clinical supervision and CPD, and why we must all speak out of it is not being followed. The benefits of this will include prevention of unnecessary medicines being prescribed, avoidance of drug related harm, and lives saved. The Prescribing Competency Framework covers 10 areas, all of which are essential to medication safety (the version in this blog was updated in May 2022). In plain language they are: The consultation Assessment of the patient’s presenting complaint and medical history and other areas such as medicines history, adherence[3] and Safeguarding. Prescribing options (including stopping / reducing medicines). Always Involving the patient, including reaching a ‘shared decision’ on the treatment, or respecting the patient’s right to refuse.[3] Writing legible / legal prescriptions, with full & unambiguous directions. Providing information on medicines & following this up with the patient. Monitoring and reviewing the effect of medicines and acting on this. Prescribing governance Safe prescribing, including ensuring that allergies, sensitivities, adverse reactions, and interactions are acted on appropriately. Prescribing professionally, including record keeping, staying up to date on guidance and following all related laws (e.g. the Mental Capacity Act)[4]. Improving prescribing practice through audit, clinical supervision, clinical governance, meaningful patient involvement and continuing professional development. Prescribing as part of a multi-disciplinary team, and as part of wider inter-disciplinary care plan(s), in all settings Since the advent of ‘non-medical prescribing’ (i.e. prescribing by healthcare professionals other than doctors) over 15 years ago, prescribing has been a subject that is taught and assessed at Universities. Only experienced and specifically qualified registered healthcare professionals can prescribe medicines. Becoming a non-medical prescriber involves an in-depth course of both written and oral (scenario based) assessment, and not all who undertake it pass. The bedrock of this course is the Prescribing Competency Framework. Embedding the framework In view of the obvious benefits of following a competency framework for prescribing, here are some questions for reflection: 1. Do the prescribers in your team use the competency framework? 2. Is the competency framework part of the prescribing CPD in your organisation? 3. Is the competency framework used as part of prescribers’ annual appraisals? 4. How is prescribing competency monitored in your organisation, and is the competency framework included in clinical supervision? 5. Does your organisation use the prescribing competency framework in clinical governance sessions? 6. Is the prescribing competency framework referred to in incident investigation reports? The framework is missing from the narrative of major investigations I can find great examples of the implementation and the resulting patient safety benefits of points 1 to 5 above. Although I am saddened to see references to the prescribing competency framework missing in major investigations, inquests, and related commentaries. Elizabeth Dixon Major examples of failings where prescribing competency was a contributory factor include the death of Elizabeth Dixon[5]. It appears that a failure to review opiate prescribing, and failings in inter-disciplinary communication and monitoring of medicines may have contributed to her death. ‘…the daily dose of morphine was increased over fivefold. While this may be an appropriate pattern in a child with progressive and painful malignant disease nearing the end of life, there was no evidence that this was the case for Elizabeth. The repeated increases in morphine administration are likely to have contributed further to the tendency for secretions to accumulate in the tracheostomy tube and require frequent suctioning.’[5] Oliver McGowan Another case where the competency in prescribing is relevant is that of Oliver McGowan, a teenager with autism and mild learning disability. He died in 2016 following experiencing neuroleptic malignant syndrome after administration of an antipsychotic medicine that he had previously reacted adversely to. Oliver did not have a mental illness, psychosis or a history of challenging behaviour. He was prescribed an antipsychotic medicine despite a number of prescribing 'red flags' being present. This medicine was listed in the ‘allergies’ column of his drug chart and in his ‘Hospital Passport’, his parents and Oliver himself had asked not to be given the medicine, an alternative non-drug related option had been recommended, and an email had been sent by A&E doctors warning of Oliver’s sensitivity to antipsychotics. I recommend prescribers study this case and look the available information, which I attempted to summarise in a presentation in 2019. At the inquest into Oliver’s death the coroner concluded that his care was ‘appropriate’[6] and was reported as saying that Oliver’s medicines were ‘properly prescribed’. There followed a Learning from Deaths Review [LeDeR] into Oliver’s death. This made no recommendations. This review was met with incredulity by Oliver’s parents, and by some clinicians. As a result, there was a review into the LeDeR process for Oliver McGowan[7]. This review, which covered the process of the first review only, was highly critical. It found that the author of the first LeDeR review felt bullied into toning down the initial report, and subsequently left her job: ‘The interviewer asked what would have happened if she had not done this. Ms A replied: I would have been sacked, no doubt about it, they never said this, but I knew’ ‘…I could never work there again’ As far as I am aware there have been no specific recommendations in relation to prescribing because of Oliver McGowan’s death, and the prescribing competency framework has not been mentioned in any related NHS report or commentary. Richard Handley Other cases where prescribing competency is a factor include that of Richard Handley, who died from complications because of constipation. Richard was a 33-year-old adult with Down’s syndrome and a moderate learning disability who was also diagnosed with a mental illness and hypothyroidism and had lifelong problems with constipation. I also understand, for reading about this tragic case that Richard was prescribed medicines which had a side-effect of constipation. A serious case review[8] in 2015 identified multiple failings, however prescribing is not specifically listed. I believe this is a missed opportunity for learning and include discussion of Richard’s case in my teaching on medicines and prescribing. In writing this piece I was surprised to discover that the prescribing competency framework does not appear to have been referenced in any of the reports mentioned above. Final thoughts Given the annual expenditure on medicines with the benefits and risks involved in their use, it seems surprising to me that the art and science of prescribing medicines receives so little attention in investigation reports, and from public bodies. I believe patients, the public and healthcare practitioners need to be aware of the Prescribing Competency Framework and why the framework must be applied in practice, used in clinical supervision and CPD, and why we must all speak out if we believe it is not being followed. At present it appears that, since the demise of the National Prescribing Centre, no national body is picking up on this need for more awareness, training and education specifically related to prescribing. I believe that patients are being harmed and lives may be being lost as a direct result of this gap in learning. May 2022 update: The Oliver McGowan Mandatory Training in Learning Disability and Autism has now been launched after passing into law as part of the Health and Care Act 2022. The training aims to ensure that staff working in health and social care receive learning disability and autism training, at the right level for their role. In an interview for Woman's Hour, Oliver's mum Paula talks about Oliver and the events that led to his death, as well as discussing the new mandatory training. References University of Sheffield, More than 200 million medication errors occur in NHS per year, say researchers, 23 February 2018. Royal Pharmaceutical Society, Prescribing Competency Framework for all Prescribers, September 2021. National Institute for Health and Care Excellence, Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. NICE Clinical Guideline CG76, 28 January 2009. UK Government, How to make decisions under the Mental Capacity Act 2005, 30 September 2014. Dr Bill Kirkup CBE, The life and death of Elizabeth Dixon: a catalyst for change, November 2020. INQUEST, Coroner concludes care of Oliver McGowan was ‘appropriate’ despite parents’ pleas not to use medication which led to the teenager’s death, 20 April 2018. Fiona Ritchie OBE, Independent Review into Thomas Oliver McGowan’s LeDeR Process Phase two, (8, 7, 12. & 7.19), October 2020. Flynn Margaret and Eley Ruth, A serious case review: James’ Suffolk Safeguarding Adults Board (restricted access), Social Care Institute for Excellence, 2015.
  25. Content Article
    Health information technology (HIT) provides many benefits, but also facilitates certain types of errors, such as wrong-patient errors in which one patient is mistaken for another. These errors can have serious patient safety consequences and there has been significant effort to mitigate the risk of these errors through national patient safety goals, in-depth research, and the development of safety toolkits. Nonetheless, these errors persist. In this study, Kim et al. analysed 1,189 patient safety event reports using a safety science and resilience engineering approach, which focuses on identifying processes to discover errors before they reach the patient so these processes can be expanded. They analysed the general care processes in which wrong-patient errors occurred, the clinical process step during which the error occurred and was discovered, and whether the error reached the patient. For those errors that reached the patient, they analysed the impact on the patient, and for those that did not reach the patient, we analysed how the error was caught. The results demonstrate that errors occurred across multiple general care process areas, with 24.4% of wrong-patient error events reaching the patient. Analysis of clinical process steps indicated that most errors occurred during ordering/prescribing and most errors were discovered during review of information. Patients were primarily impacted by inappropriate medication administration and the wrong test or procedure being performed. When errors were caught before reaching the patient, this was primarily because of nurses, technicians, or other healthcare staff. The differences between the general care processes can inform wrong-patient error risk mitigation strategies. Based on these analyses and the broader literature, this study offers recommendations for addressing wrong-patient errors using safety science and resilience engineering, and it provides a unique lens for evaluating HIT technology wrong-patient errors.
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