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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 unsa- Posted
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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, de- Posted
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The Prescribing Competency Framework covers 10 areas, all of which are essential to medication safety. 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.- Posted
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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 ho- Posted
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News Article
New partnership to improve patient safety in South East London ICS
Clive Flashman posted a news article in News
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, achievin- Posted
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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 sol- Posted
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NHS compensation payouts have doubled in six years, figures show
Patient Safety Learning posted a news article in News
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 h- Posted
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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.- Posted
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untilPatient 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- Posted
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1,000-year-old eye infection potion found to tackle antibiotic-resistant infections
Clive Flashman posted a news article in News
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.- Posted
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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.- Posted
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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 deli- Posted
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This is a template that can be used by health professionals carrying out medicines reconciliation.- Posted
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ECRI - Top 10 Patient Safety Concerns 2020
Claire Cox posted an article in Maternity
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 lea- Posted
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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.- Posted
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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: -
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PRSB podcast: Making medications safer
Patient Safety Learning posted an article in Medication including labelling
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.- Posted
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PHE: Become an antibiotic guardian
Claire Cox posted an article in Medicine management
Choose one simple pledge about how you’ll make better use of antibiotics and help save these vital medicines from becoming obsolete.- Posted
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Antibiotic awareness: quizzes and crosswords (updated 2017)
Claire Cox posted an article in Medicine management
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ThinkSAFE Medications list
Claire Cox posted an article in Keeping patients safe
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Bottle of Lies by Katherine Eban
Patient Safety Learning posted an article in Recommended books and literature
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