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Found 171 results
  1. Content Article
    There has been an big increase in the use of diabetes technology in the NHS recently, especially in type 1 diabetes. Continuous glucose monitors (CGMs) are now standard care for people with type 1 diabetes, and work has begun to increase access to hybrid closed loop (HCL) systems, which are sometimes referred to as an 'artificial pancreas'. Along with this expansion, it is important to raise awareness of these devices when people with diabetes are admitted to hospital, whether this is directly for their diabetes or not. This information poster, developed by Mayank Patel and the diabetes team at University Hospital Southampton, aims to raise awareness of diabetes tech devices. It also addresses the issue of safe insulin delivery, especially related to pumps.
  2. Content Article
    Children are at higher risk of medication errors due to the complexity of drug prescribing and administration. Intravenous (IV) paracetamol overdose differs from overdose by ingestion as there is no enteral absorptive buffering. This study outlines the first national UK data focusing on paediatric IV paracetamol poisoning. The data show that unintentional IV paracetamol overdose appears to occur more frequently in young children. A significant proportion of errors were calculation errors, which were often 10-fold errors. While these errors have the potential to cause serious harm, thankfully most cases were asymptomatic. Errors with IV paracetamol might be reduced by electronic prescribing support systems, better communication regarding administration and consideration of whether other routes are more appropriate.
  3. Content Article
    People with Parkinson’s need their medication on time every time. Yet over half of people with the condition don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death. Parkinson's UK are campaigning to make sure that no one with Parkinson’s is worried that they will leave hospital more unwell than when they went in.  Whether you have Parkinson’s, support someone who does, work in the health and care system or campaign to improve it, you can take action to make hospitals and care homes safer.  Together we can get more people to understand how big this problem is. And we can put pressure on the right people, across the UK, to change hospital policies, improve prescribing in hospitals and make sure staff are trained to give time critical medication.
  4. Content Article
    Intravenous drug administration has been associated with severe medication errors in hospitals. This narrative review and aimed to describe the recent evolution in research on systemic causes and defences in intravenous medication errors in hospitals. It highlights a growing interest in systems-based risk management for intravenous drug therapy and in introducing new technology, particularly smart infusion pumps and preparation systems, as systemic defences. The authors conclude that when introducing new technologies, prospective assessment and continuous monitoring of emerging safety risks should be conducted.
  5. Content Article
    This article reflects on the death of Wayne Jowett and the impact this had on how the NHS approaches patient safety. Wayne died after the cytotoxic drug vincristine, intended for intravenous injection, was instead injected into his spine. The circumstances around his death informed the subsequent development of Serious Reportable Events in the NHS, and later the Never Events Framework.
  6. Content Article
    Patients with Parkinson’s are at risk of significant harm if they don’t get their medication on time, every time. ‘On time’ means within 30 minutes of the patient’s prescribed time. Even short delays can worsen symptoms such as rigidity, pain and tremors, increasing the risk of falls. Over half of people with Parkinson’s don’t get their medications on time, every time in hospital. This leads to worse patient outcomes, longer recovery times and increased costs to the NHS.
  7. Content Article
    Harm due to medicines and therapeutic options accounts for nearly 50% of preventable harm in medical care. This World Health Organization (WHO) policy brief is a resource for policy-makers, health workers, healthcare leaders, academic institutions and other relevant institutions to help understand the global burden of medication errors, address and prevent medication-related harm at all levels of healthcare, aligned with the strategic plan of the third WHO Global Patient Safety Challenge: Medication Without Harm. 
  8. Content Article
    Peripheral nerve blocks (PNB) are safe and effective alternatives or supplements to general anaesthesia. They may improve pain control both during and after surgery, thus avoiding many of the side effects of systemic opioids. PNBs may also lead to improved patient satisfaction, decreased resource utilization, and may be better for the environment by decreasing usage of aesthetic gases and other medications. With the growing use of peripheral nerve blocks in the United States, this paper examines safety issues surrounding the procedures. It examines the safety of nerve blocks as it relates to: nerve injury recognition and treatment of local anaesthetic systemic toxicity (LAST) appropriate health care professional performance of timeouts to avoid wrong-site blocks.
  9. Content Article
    Ashleigh Hughes is a Senior Sister at an NHS chemotherapy day unit. In this interview she shares her personal story about the impact of antibiotic underdosing on her Mum’s end of life care. Antibiotic underdosing is a medication safety issue that has profound implications for the health service as well as individual patients, but there is currently a lack of understanding and recognition of the issue.
  10. Content Article
    Antibiotic underdosing is a widespread issue in the healthcare system. The use of modern infusion pumps to deliver intravenous (IV) medications has resulted in the practice of flushing IV lines being lost in some specialties. Failure to give full doses of IV antibiotics poses significant risks to individual patients as well as adding to the problem of antimicrobial resistance (AMR). In this interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT. A transcript is available below the video.
  11. Content Article
    This study aimed to assess whether the risk of 90-day mortality is comparable for individuals who switch early to oral antibiotics and those who continue intravenous (IV) antibiotics in the treatment of uncomplicated gram-negative bacteremia. The results suggest that transition to oral antibiotics within four days after initial blood culture may be an effective alternative to prolonged IV antibiotic treatment for uncomplicated gram-negative bacteremia.
  12. News Article
    The EU is to stockpile key medicines that will worsen the record drug shortages in the UK, with experts warning that the country could be left “behind in the queue”. The EU is seeking to safeguard its supplies by switching to a system in which its 27 members work together to secure reliable supplies of 200 commonly used medications, such as antibiotics, painkillers and vaccines. But the bloc’s move to insulate itself from growing drug shortages threatens to exacerbate the increasing scarcity of medicines facing the NHS, posing serious problems for doctors. “Europe is securing access to key drugs and vaccines as a single region, with huge influence and buying power. As a result of Brexit the UK is now isolated from this system, so our drug supplies could be at risk in the future,” said Dr Andrew Hill, an expert on the pharmaceutical trade. Britain is experiencing a record level of drug shortages, with more than 100 – including treatments for cancer, type 2 diabetes and motor neurone disease – scarce or impossible to obtain. Mark Dayan, the Brexit programme lead at the Nuffield Trust health thinktank, said the EU’s decision to act as a buying cartel could seriously disadvantage Britain. “There is a real risk that measures in such a large neighbour, which is now a separate market due to Brexit, will leave the UK behind in the queue when shortages strike,” Dayan said. It also has an initiative for member states to transfer stocks of medicine to cover shortages in others. These measures could shut UK purchasers out in certain scenarios. “This would risk worsening shortages from a starting point where they are already exceptionally severe for the UK and other countries, with a mounting impact in terms of costs and wasted time for the NHS, and in terms of patients struggling to get what their doctors have said they need.” Read full story Source: The Guardian, 25 January 2024 Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy or in hospital? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our hub community thread on the topic here or drop a comment below. You'll need to register with the hub first, its free and easy to do.
  13. Content Article
    Connections are critical junctures and points of access along intravenous (IV) lines. Microorganisms may colonise these connections, potentially leading to catheter-related bloodstream infections (CRBSIs). For patients, CRBSIs are a significant cause of morbidity and death, and for healthcare facilities these infectious complications lead to unnecessary costs. Safe connections may help reduce the risk of needlestick injuries for healthcare professionals (HCPs) and the occurrence of CRBSIs for patients. In this webinar recording, Nancy Trick, Registered Nurse and Adjunct Instructor at Perdue Global University in West Lafayette, USA, discusses CRBSIs and presents solutions to help prevent them. After watching this webinar, you should be able to: describe open versus closed infusion systems in VAM. briefly discuss the clinical risks of open infusion systems. discuss clinical practice change. consider how evidence-based standards of practice recommend using closed IV access/needleless connectors.
  14. Content Article
    The Parkinson’s Excellence Network has launched three new practical guides to support UK health professionals to deliver time critical Parkinson’s medication on time in hospital.
  15. Content Article
    The objective of this systematic review from Benhamou et al. was to assess the clinical, economic, and health resource utilisation outcomes associated with the use of prefilled syringes in medication administration compared with traditional preparation methods. The findings provide new insights into clinical and economic benefits of prefilled syringe adoption. These benefits include improved medication delivery and safety, which can lead to time and cost reductions for health care departments, hospitals, and health systems. However, further real-world research on clinical and economic outcomes, especially in contamination, is needed to better understand the benefits of prefilled syringes.
  16. Event
    This conference focuses on improving practice and patient safety to reduce extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce extravasation injury. Learn from outstanding practice in recognizing, treating and escalating extravasation injury. Reflect on national developments and learning. Ensure vesicants are administered in the safest way. Develop your skills in training frontline staff to recognise evolving injuries. Understand how you can implement preventative measures. Identify key strategies for improvement. Educate patients to raise alarm and improve consent procedures. Develop protocols to support practice. Understand the role and competencies of the NHS trust lead for extravasation. Ensure effective treatment, and early intervention in severe wounds. Learn from case studies in cancer, maternity, radiology and paediatrics. Ensure you are up to date with the latest legal cases. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/iv-therapy-summit-2023 or email kerry@hc-uk.org.uk Follow on Twitter @HCUK_Clare #IVTherapy hub members receive a 20% discount. Email info@pslhub.org for discount code.
  17. Content Article
    On 11 January 2021 an investigation into the death of Susan Ann Gladstone was started. The investigation concluded at the end of the inquest on 20 November 2023. The conclusion of the inquest was Susan died as a result of a generally unknown interaction between warfarin and tramadol which caused exceptional thinning of her blood: 1a Intraparenchymal and subarachnoid haemorrhage.
  18. News Article
    NHS England has been told it must take action to raise awareness about the potentially fatal interaction between tramadol and warfarin, following the death of a patient. Graham Danbury, assistant coroner for Hertfordshire, issued a prevention of future deaths report on 1 December 2023, after Susan Gladstone, from Hertfordshire, died on 8 January 2021 from a bleed in the brain. An inquest, which ended on 20 November 2023, concluded that Gladstone “died as a result of a generally unknown interaction between warfarin and tramadol, which caused exceptional thinning of her blood”. Gladstone was prescribed tramadol twice for lower back pain: on 20 December 2020 and 4 January 2021. According to the report, she had been taking the anticoagulation medication warfarin for “a number of years”. The report continues: “There was nothing to warn the prescribing doctor of any possible interaction. I found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event, fatal INR to develop. “In my opinion, actions should be taken to prevent future deaths and I believe you, NHS England, have the power to take such action.” Read full story Source: Pharmaceutical Journal, 13 December 2023
  19. News Article
    An "evil" nurse who drugged patients on a stroke unit for an "easy shift" and a healthcare worker who conspired with her have been jailed. Catherine Hudson, 54, was found guilty of giving unprescribed sedatives to two patients at Blackpool Victoria Hospital in 2017 and 2018. She was also convicted of conspiring with Charlotte Wilmot, 48, to give a sedative to a third patient. Hudson was jailed for seven years and two months. Wilmot was sentenced to three years. Evidence during the trial highlighted the "dysfunctional" drugs regime on the stroke ward with free and easy access to controlled drugs and medication which led to "wholesale theft" by staff. Prosecutors described it as a "culture of abuse" after police examined WhatsApp phone messages between the co-defendants and other members of staff. The pair were investigated after a student nurse witnessed events while on a work placement on the stroke unit and told senior managers in November 2018, who called in police. The whistleblowing nurse, who the prosecution had asked not to be named, told officers she had concerns over the use of insomnia medication Zopiclone, which can be life-threatening if given inappropriately. She said Hudson had told her the patient had a Do Not Resuscitate Order in place "so she wouldn't be opened up if she died or... came to any harm". Read full story Source: BBC News, 14 December 2023
  20. News Article
    An overworked nurse who failed to give medication to a patient told a colleague “I don’t care anymore”, a hearing was told. Niall O’loingsigh was lead nurse in the Avon unit within the Charterhouse Care Home in Keynsham, Somerset, which looks after elderly residents and those with dementia. In 2020 a complaint was made by a colleague about him breaching safe medication management protocols and being dishonest in relation to medication administration. A misconduct hearing at the Nursing and Midwifery Council was told later, in May 2021, he was seen behaving in an “unsupportive manner” and told a colleague: “I don’t care anymore”. The panel also heard how on 18 May 2021, Mr O’loingsigh failed to record he had administered medication to three residents, BristolLive reported. A colleague wanted to report Mr O’loingsigh’s conduct, in which Mr O’loingsigh patted her on the back and said “well done mate, you did the right thing but I may lose my PIN though”. Mr O’loingsigh told his colleague of feelings of distress and anxiety about being reported and its impact on his career, but he wanted to reassure her. The colleague however felt “uncomfortable”. The panel found that he underwent “a course of conduct which put patients at risk of suffering harm at the time of the incidents” and noted “there were repeated failures over a period of time”. Read full story Source The Mirror, 10 December 2023
  21. News Article
    The under delivery of intravenous antibiotics in some NHS hospitals due to lack of polices and compliance may be contributing to antimicrobial resistance (AMR), according to a parliamentary report. Findings in the report indicated that many health service organisations do not have policies in place to reduce the risk of under delivery and those that do can struggle to comply fully with them. The report’s authors warned that the residual volume of antibiotic remaining in the line of the IV administration set can result in under delivery of up to 30% of the prescribed dose. They said that, as a result, this could be leading to possible resistance within patients, owing to the accumulative effect. Nurses involved with compiling the document have called for action. Based on the findings, the report recommended that all NHS organisations implement line flushing policies by late 2024, with support from the Department for Health and Social Care. Read full story (paywalled) Source: Nursing Times, 9 December 2023 Further reading on the hub: Short-term intermittent IV antibiotics – Understanding the issue of under delivery Understanding the importance of accurate antibiotic administration through an IV administration set (drip): A patient’s guide Top picks: 10 key resources on antimicrobial resistance
  22. News Article
    We have the technology to start a new era in medicine by precisely matching drugs to people's genetic code, a major report says. Some drugs are completely ineffective or become deadly because of subtle differences in how our bodies function. The British Pharmacological Society and the Royal College of Physicians say a genetic test can predict how well drugs work in your body. The tests could be available on the NHS next year. It would have helped Jane Burns, from Liverpool, who lost two-thirds of her skin when she reacted badly to a new epilepsy drug. She was put on to carbamazepine when she was 19. Two weeks later, she developed a rash and her parents took her to A&E when she had a raging fever and began hallucinating. The skin damage started the next morning. Jane told the BBC: "I remember waking up and I was just covered in blisters, it was like something out of a horror film, it was like I'd been on fire." Jane's experience may sound rare, but Prof Mark Caulfield, the president-elect of the British Pharmacological Society, said "99.5% of us have at least one change in our genome that, if we come across the wrong medicine, it will either not work or it will actually cause harm." "We need to move away from 'one drug and one dose fits all' to a more personalised approach, where patients are given the right drug at the right dose to improve the effectiveness and safety of medicines," said Prof Sir Munir Pirmohamed, from the University of Liverpool. Read full story Source: BBC News, 29 March 2022
  23. News Article
    Millions of people wrongly believe they are allergic to penicillin, which could mean they take longer to recover after an infection, pharmacists say. About four million people in the UK have the drug allergy on their medical record - but when tested, 90% of them are not allergic, research suggests. The Royal Pharmaceutical Society says many people confuse antibiotic side-effects with an allergic reaction. Common allergic symptoms include itchy skin, a raised rash and swelling. Nausea, breathlessness, coughing, diarrhoea and a runny nose are some of the others. But antibiotics, which treat bacterial infections, can themselves cause nausea or diarrhoea and the underlying infection can also lead to a rash. And this means people often mistakenly believe they are allergic to penicillin, which is in many good, common antibiotics. These are used to treat chest, skin and urinary tract infections - but if people are labelled allergic, they are given second-choice antibiotics, which can be less effective. Read full story Source: BBC News, 28 September 2023
  24. News Article
    A mental health trust has been served with a warning notice ordering improvements in its processes around rapid tranquillisation of patients. The Care Quality Commission said the trust needed to ensure all staff at Kent and Medway NHS and Social Care Partnership Trust followed local and national recommendations to monitor and record a patient’s physical health when rapid tranquillisation was administered. Inspectors were concerned staff were not always aware of the potential impact of these medications. Serena Coleman, CQC deputy director of operations in the south, said: “We found some staff weren’t always using the least restrictive options to make sure that people’s behaviour wasn’t controlled by an excessive use of medicines. “As required medication, such as lorazepam and promethazine, was being used quite frequently but we couldn’t always find records to explain why these medications were necessary. There were examples where reviews hadn’t happened for long periods, meaning staff couldn’t be sure it was still appropriate to administer to people." Read full story (paywalled) Source: HSJ, 3 August 2023
  25. News Article
    Hospitals must start using “smart” intravenous (IV) infusion technology to its full potential if they are to prevent dangerous drug errors, University of Manchester researchers have found. ‘Smart pumps’- which automatically calculate the dose and rate of different drugs before they are pumped into a vein - prevent potentially fatal errors by stopping the administration of the wrong rate. But according to the study published in BMJ Open Quality, though the technology probably saved the lives of 110 people in two Trusts over a year, it has largely failed to be adopted by hospitals. Though many IV pumps used in hospitals have a smart capability, most trusts do not utilise the functionality because they are difficult to configure and maintain. Smart pumps are usually configured by a pharmacist and checked by a consultant or senior nurse. Conventional pumps, however, are set by ward staff who calculate and input infusion rates themselves - increasing the risk of drug errors. The risks are illustrated by previous work from the Manchester team, who demonstrated that 1 in 10 IV drug administrations are associated with an error, and up to 1 in 10 of those were associated with harm. Read full story Source: University of Manchester, 1 August 2022
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