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Found 22 results
  1. Content Article
    Advice for healthcare professionals do not use glucose-containing solutions as infusates for maintaining arterial line patency, unless there are no suitable alternatives saline infusions are recommended as the flush solution for arterial lines, to minimise the risk of incorrect blood glucose estimation and inappropriate insulin administration if samples are drawn from arterial lines for estimation of biochemistry, a minimum volume of three times the dead space of the cannula system should be discarded first to avoid contamination[^4] remain vigilant when selecting a solution for arterial line infusate. Similarities between glucose and saline solution bags means that confusion may occur ensure that the arterial infusion line length is kept to the minimum necessary.
  2. 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
  3. Community Post
    See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
  4. Event
    until
    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 following day and so these issues should be at the forefront of policy makers minds. Confirmed panelists include: Prof. Liz Kay, Former Director of Pharmacy at Leeds Teaching Hospitals NHS Trust Heather Randle, Lead for Medication Management at Royal College of Nursing Clive Flashman, Chief Digital Officer at Patient Safety Learning Ed Platt, Automation Director, Omnicell Registration
  5. 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.
  6. 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
  7. Content Article
    The procedure describes immediate action to ensure patient safety, grading of errors (where appropriate) and longer term actions to ensure that individuals, team, group and organisation can learn from errors. This policy is specifically written for all registered staff involved in the prescribing, dispensing, administering or monitoring of medication. The policy is also relevant for managers of such staff and gives instruction for managing staff who have been involved in a medication error.
  8. Content Article
    OptiMed-ID is an innovation unique within the UK, which uses robotic technology and logistics software to produce and deliver individual doses of medication within an acute hospital setting. It enables complete control of medicine prescribing, supply and administration, reducing medication errors and cutting waste. Already deployed and delivering significant cost savings in 20 hospitals in Italy, the independent evaluation work – completed December 2015 – has confirmed that the use of “optimisation of medicines with individual dosing” (OptiMed-ID) in an NHS acute hospital setting can deliver drugs cost savings in excess of 25%. Deployed throughout four wards at UHL, this is the first time that an automated individual medicines dosing solution has been brought into operational use in the UK. The evaluation report has informed UHL’s decision to extend the pilot whilst business case and procurement activities for the rollout of the innovation throughout the whole trust are completed. The trust-wide deployment at Leicester is expected to deliver savings to the NHS of around £4m per annum, as well as improving medicines adherence and reducing the risk of medicine errors.
  9. Content Article
    ECRI’s list of patient safety concerns for 2020: 1. Missed and delayed diagnoses—Diagnostic errors are very common. Missed and delayed diagnoses can result in patient suffering, adverse outcomes, and death. 2. Maternal health across the continuum—Approximately 700 women die from childbirth-related complications each year in the U.S. More than half of these deaths are preventable. 3. Early recognition of behavioural health needs—Stigmatisation, fear, and inadequate resources can lead to negative outcomes when working with behavioural health patients. 4. Responding to and learning from device problems—Incidents involving medical devices or equipment can occur in any setting where they might be found, including ageing services, physician and dental practices, and ambulatory surgery. 5. Device cleaning, disinfection, and sterilisation—Sterile processing failures can lead to surgical site infections, which have a 3% mortality rate and an associated annual cost of $3.3 billion. 6. Standardising safety across the system—Policies and education must align across care settings to ensure patient safety. 7. Patient matching in the EHR—Organisations should consistently use standard patient identifier conventions, attributes, and formats in all patient encounters. 8. Antimicrobial stewardship—Over prescribing of antibiotics throughout all care settings contributes to antimicrobial resistance. 9. Overrides of Automated Dispensing Cabinets (ADC)—Overrides to remove medications before pharmacist review and approval lead to dangerous and deadly consequences for patients. 10. Fragmentation across care settings—Communication breakdowns result in readmissions, missed diagnoses, medication errors, delayed treatment, duplicative testing and procedures, and dissatisfaction.
  10. Content Article
    This information pack is aimed at healthcare students from any role/sector. It has an array of resources to be downloaded including: an e-learning module on Anti microbial resistance (AMR) shared learning articles from other trusts a video explaining what AMR is a range of blogs leaflets and infographics quizzes.
  11. 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.
  12. Content Article
    Choose one simple pledge about how you’ll make better use of antibiotics and help save these vital medicines from becoming obsolete.
  13. Content Article
    The full report provides several tools to assist with implementation of the recommendations, including a checklist of safe practices for improving drug allergy CDS and an educational PowerPoint file describing the workgroup’s findings and recommendations, which can be used to garner support for the organisation’s effort.
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