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Content ArticleAn HSIB guest blog post from Henrietta Hughes introducing her vision for her new role as Patient Safety Commissioner.
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Content Article
Deprescribing. 'Do I really need this medicine?'
Patient Safety Learning posted an article in Medicine management
Overprescribing effects patient’s experience of, and engagement with, health and care services. It results in unnecessary costs and harm to patients. Watch this short video from Steve Turner. Reflection and key learning points based on UK laws and guidelines. -
Content ArticleAccording to a recent research study published in the journal Annals of Internal Medicine, over a million people with diabetes in the US rationed their insulin in the past year. When people with diabetes ration their insulin, either by taking less than they need or skipping doses, it poses a serious safety risk and has a negative impact on their long-term health. This article highlights that the main cause of insulin rationing is the high cost of insulin in the US, with pharmaceutical companies increasing prices annually even though the product remains the same. It outlines the main issues caused by insulin rationing and looks at the need for reform to ensure that all Americans with diabetes are able to access adequate insulin. The author speaks to Stephanie Arceneaux who has had type 1 diabetes for 30 years. Stephanie describes her experiences of deciding whether or not to eat and therefore use more insulin, and of having to ration blood glucose test strips.
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Content ArticleInflammatory rheumatic disease (IRD), such as rheumatoid arthritis, can cause poor outcomes in pregnancy, and the health of the mother and developing foetus must be balanced when making decisions about medication. This updated guideline from the British Society for Rheumatology contains evidence and best practice for prescribing rheumatology medications during pregnancy and breastfeeding. It includes a table that summarises information about drug compatibility in pregnancy and breastfeeding.
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Content Article
Blog - Is human error a crime? (2 November 2022)
Patient-Safety-Learning posted an article in Legal matters
Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place. -
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BD - Voices of safety videos
Patient-Safety-Learning posted an article in Patient stories
This series of videos produced by pharmaceutical company BD features patients, caregivers and healthcare professionals telling their stories about patient safety. Each video highlights an experience of avoidable harm, with topics including sepsis, antimicrobial resistance, medication errors and healthcare associated infections. -
Content ArticleIn this analysis, published by the Human Factors and Ergonomics Society, the authors look at the impact of double checking medication to reduce errors and improve patient safety.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) third annual conference took place on 21 September 2022. Presentations and videos from the day are now available to view and download below. Although it tied in with the World Health Organization’s World Patient Safety Day theme of medication safety, our speakers also covered: how we can drive system level change practical sessions based on our HSIB investigation education courses maternity safety insights themed around inclusivity of care opportunities for sharing and learning from Norway’s healthcare safety investigation body, UKOM.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency (MHRA) is reviewing its approach to engagement with healthcare professionals to improve the safety of medicines and medical devices. It wants to ensure that healthcare professionals are receiving actionable information and guidance on safe use of medicines and medical devices that they can take into their working practice, providing timely advice to patients. The MHRA wants to hear from you to enable them to transform how they communicate with you and how they work together with you for the common goal of greater patient safety. The consultation closes 18 January 2023.
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Content ArticleWhen leaving hospital with medicines, there can be a lot of information to take in. This checklist designed by the Royal College of Physicians (RCP) Quality Improvement and Patient Safety (QIPS) is designed to help patients and their carers use medications safely when they leave hospital. It includes: Questions to consider before you leave hospital Questions to consider when you’ve left hospital Further useful resources Medicines safety and governance pharmacist Jen Flatman has written a blog about how the checklist was developed.
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Content ArticleIn this blog, Jen Flatman, medicines safety and governance pharmacist, discusses a resource to support people to continue to use their medicines safely once they leave hospital. The medicines safety checklist was designed by patients and carers, for patients and carers, helping bridge the transition between hospital and the next destination. The points on the checklist are designed to act as a prompt, ensuring individuals are aware of key information to continue to use their medicines safely. They also act as a reminder to the reader to ask questions if they are unsure about anything.
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Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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Content ArticleThis guidance from the Irish Health Services Executive (HSE) aims to help healthcare staff improve venous thromboembolism (VTE) prevention in hospitals. Hospital-acquired blood clots, or VTE, are the most common preventable cause of in-hospital death. Assessing patients’ risk of VTE and bleeding and choosing the appropriate thromboprophylaxis such as medicines or compression stockings early in their hospital admission reduces their risk of developing a blood clot.
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Content ArticleRichard von Abendorff's elderly mother died an avoidable, painful death in hospital due to being inappropriately prescribed Nalaxone. In this article, Richard outlines the steps he has taken to try and ensure lessons are learned from his mother's experience. Eventually, in 2014 NHS England published a patient safety alert relating to inappropriate doses of naloxone in patients on long-term opioid treatment. A coroner’s palliative expert report identified issues contributing to Richard's mother's poor end of life care, noting that purely advisory palliative services in an acute hospital setting are ‘not fit for purpose’ to meet the needs of more complex dying patients. Richard expresses his frustration at an ongoing lack of interest and action related to substandard end of life care.
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AvMA case study: Stuart's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of Stuart, who died as a result of medication errors while recovering from surgery at a private hospital in January 2013. Stuart had dystonia, an incurable condition that he managed by taking a careful balance of three medications. Following surgery to remove his larynx, the private neurological centre where he was staying ran out of clonazepam, a medication Stuart needed to control his dystonia. Stuart became very unwell, but instead of seeking advice from a doctor, the nurses treated his symptoms as a UTI. on 26 December he was found unresponsive in bed and rushed to ICU at a local hospital. but died a few weeks later from sever kidney and muscle damage. An inquest into Stuart's death found that the lack of clonazepam had caused an increase in Stuart’s muscle spasms, eventually leading to severe muscle and kidney damage. He then developed bronchopneumonia, which was the final factor in his death. -
Content Article
AvMA case study: Lyndsey's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of Lyndsey, who was 36 years' old and expecting her third child when she died of shock and haemorrhage, and a perforated gastric ulcer. Sadly, her baby also died as a result of Lyndsey's condition. In her narrative report, the Coroner raised concerns that Lyndsey had been prescribed methadone with no face-to-face consultation, and that she had received a prescription with no planned medical review. She also raised concerns about the reliability of the ambulance pre-alert system due the absence of systems for auditing the effectiveness and reliability of the pre-alert system and the lack of knowledge and training of staff in control. -
Content ArticlePreventable harm, from the systems of care intended to improve health, continues to occur at an unacceptable rate in the United States. Healthcare systems have an opportunity to learn and improve from each episode of preventable harm. Accordingly, every preventable patient death or injury must energise our efforts to prevent future patient harm. The Anesthesia Patient Safety Foundation (APSF) believes that criminal prosecution of healthcare providers will make the work of preventing harm more difficult since it continues to shift the focus away from system improvements. They have released a position and policy statement outlining the rationale for opposing criminal prosecution and, equally important, recommends that all healthcare systems and organisations aggressively act, now, to improve their culture, processes, and training to reduce errors of all kinds and, specifically in light of recent events, medication errors. Some specific actions are recommended as examples of what can be done. Individual healthcare professionals should be mindful of their role in preventing errors and reporting errors that occur as well as taking action to encourage and enable their organization to improve the flaws in the systems in which they work that lead to harm to patients.
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Content ArticleThe last 10 years have seen substantial growth in medical devices that can help people with diabetes to manage their condition, including the development of automated insulin delivery (AID) systems. Regulatory approval has been granted for the first AID systems, and a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach. This consensus report from the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association offers a review of the current landscape of AID systems and recommends targeted actions.
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Content ArticleWhen something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what the Care Quality Commission (CQC) and the provider have done about it, and the steps you can take to avoid it happening in your service.
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Content ArticlePatient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasised the importance of engagement in developing safety solutions.
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Content Article“Can I use a teaspoon to measure my cough syrup?” “Is it ok to crush my pills?” “Are generic and brand name drugs really the same?” The Institute for Safe Medication Practices (ISMP) fellow and emergency room nurse, Michelle Bell, and medication safety officer for Children’s Hospital of Philadelphia, Sharon Camperchioli, answer patient questions about medication.
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Content ArticleAcute prescribing forms a large part of the daily workload for GP practices. Quality improvement (QI) methodology can be used to help improve prescribing processes and ensure that prescribing work is managed by the right member of your team, safely and effectively. This toolkit is designed to help primary care multidisciplinary teams, including pharmacotherapy services, safely improve their acute prescribing processes in line with the Essentials of Safe Care. An acute prescription is defined as any prescription without a serial or repeat mandate.
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Content ArticleThis poster highlights some key issues associated with by antimicrobial resistance (AMR), which is caused by inappropriate use of antibiotics. It outlines the objectives and results of the AMR Patient Group, a coalition of patient groups across Europe working to address the serious public health threat posed by AMR. It also outlines the AMR Patient Group's policy recommendations to European and national health authorities.
