scholarly journals Improving patient safety through education: how visual recognition skills may reduce medication errors on surgical wards

2011 ◽  
Vol 2 (1) ◽  
pp. 1
Author(s):  
Christopher R. Davis ◽  
Edward C. Toll ◽  
Paul M. Bevis ◽  
Helena P. Burden
Keyword(s):  
Patient Safety ◽  
Medication Errors ◽  
Undergraduate Education ◽  
Visual Recognition ◽  
Healthcare Professionals ◽  
Postgraduate Training ◽  
Response Rate ◽  
Recognition Rate ◽  
Compromise Patient Safety ◽  
The Uk

Medication errors compromise patient safety and cost £500m per annum in the UK. Patients who forget the name of their medication may describe the appearance to the doctor. Nurses use recognition skills to assist in safe administration of medications. This study quantifies healthcare professionals’ accuracy in visually identifying medications. Members of the multidisciplinary team were asked to identify five commonly prescribed medications. Mean recognition rate (MRR) was defined as the percentage of correct responses. Dunn’s multiple comparison tests quantified inter-professional variation. Fifty-six participants completed the study (93% response rate). MRRs were: pharmacists 61%; nurses 35%; doctors 19%; physiotherapists 11%. Pharmacists’ MRR were significantly higher than both doctors and physiotherapists (P<0.001). Nurses’ MRR was statistically comparable to pharmacists (P>0.05). The majority of healthcare professionals cannot accurately identify commonly prescribed medications on direct visualization. By increasing access to medication identification resources and improving undergraduate education and postgraduate training for all healthcare professionals, errors may be reduced and patient safety improved.

scholarly journals American Pharmacists Attitudes and Behaviors Regarding Medication Error Disclosure

2020 ◽  
Vol 11 (4) ◽  
pp. 23
Author(s):  
Jennifer Mazan ◽  
Margaret Lett ◽  
Ana Quiñones-Boex
Keyword(s):  
Patient Safety ◽  
Medication Error ◽  
Random Sample ◽  
Medication Errors ◽  
Response Rate ◽  
Community Pharmacists ◽  
Full Disclosure ◽  
Attitudes And Behaviors ◽  
Error Disclosure ◽  
And Behaviors

Background: Patient safety places emphasis on full disclosure, transparency, and a commitment to prevent future errors. Studies addressing the disclosure of medication errors in the profession of pharmacy are lacking. Objective: This study examined attitudes and behaviors of American pharmacists regarding medication errors and their disclosure to patients. Methods: A 4-page questionnaire was mailed to a nationwide random sample of 2,002 pharmacists. It included items to assess pharmacists’ knowledge of and experience with medication errors and their disclosure. The data was collected over three months and analyzed using IBM SPSS 22.0. The study received IRB exempt status. Results: The response rate was 12.6% (n = 252). The average pharmacist respondent was a 57-year old (+ 12.1 years), Caucasian (79.8%), male (59.9%), with a BS Pharmacy degree (73.8%), and licensed for 33 years (+ 12.8 years). Most respondents were employed in a hospital (26.4%) or community (31.0 %) setting and held staff (30.9%), manager (29.1%), or clinical staff (20.6%) positions.  Respondents reported having been involved in a medication error as a patient (31.0%) or a pharmacist (95.5%). The data suggest that full disclosure is not being achieved by pharmacists. Significant differences in some attitudes and behaviors were uncovered when community pharmacists were compared to their hospital counterparts.  Conclusion: There is room for improvement regarding proper medication error disclosure by pharmacists.

Does UK medical education provide doctors with sufficient skills and knowledge to manage patients with eating disorders safely?

2018 ◽  
Vol 94 (1113) ◽  
pp. 374-380 ◽  
Author(s):  
Agnes Ayton ◽  
Ali Ibrahim
Keyword(s):  
Eating Disorders ◽  
Patient Safety ◽  
Eating Disorder ◽  
Postgraduate Training ◽  
Medical Training ◽  
Improve Patient Safety ◽  
Medical Schools ◽  
Junior Doctors ◽  
The Uk ◽  
Improve Patient

BackgroundEating disorders affect 1%–4% of the population and they are associated with an increased rate of mortality and multimorbidity. Following the avoidable deaths of three people the parliamentary ombudsman called for a review of training for all junior doctors to improve patient safety.ObjectiveTo review the teaching and assessment relating to eating disorders at all levels of medical training in the UK.MethodWe surveyed all the UK medical schools about their curricula, teaching and examinations related to eating disorders in 2017. Furthermore, we reviewed curricula and requirements for annual progression (Annual Review of Competence Progression (ARCP)) for all relevant postgraduate training programmes, including foundation training, general practice and 33 specialties.Main outcome measuresInclusion of eating disorders in curricula, time dedicated to teaching, assessment methods and ARCP requirements.ResultsThe medical school response rate was 93%. The total number of hours spent on eating disorder teaching in medical schools is <2 hours. Postgraduate training adds little more, with the exception of child and adolescent psychiatry. The majority of doctors are never assessed on their knowledge of eating disorders during their entire training, and only a few medical students and trainees have the opportunity to choose a specialist placement to develop their clinical skills.ConclusionsEating disorder teaching is minimal during the 10–16 years of undergraduate and postgraduate medical training in the UK. Given the risk of mortality and multimorbidity associated with these disorders, this needs to be urgently reviewed to improve patient safety.

scholarly journals Reform Workplace Practices of Chain Pharmacies to Reduce Medication Errors

2020 ◽  
Vol 17 (02) ◽  
Author(s):  
Crystal D. Grant ◽  
Daniel J. Desautels ◽  
Jennifer Puthota
Keyword(s):  
Patient Safety ◽  
Data Collection ◽  
Health Effects ◽  
Medication Errors ◽  
Working Conditions ◽  
Pharmacy Practice ◽  
Quality Metrics ◽  
Adverse Health Effects ◽  
Compromise Patient Safety ◽  
Minimal Data

Pharmacists employed by chain pharmacies have raised concerns over corporate-mandated practices that compromise patient safety. Harsh working conditions and the pressure to meet mandated quality metrics have increased the likelihood of medication errors. Complications associated with medication errors exceed $40 billion and cause adverse health effects for hundreds of thousands of Americans annually. Despite their ubiquity, chain pharmacies face varying regulations as state pharmacy boards dictate individual statewide policies. There is minimal data collection on pharmacy practices and state pharmacy boards do not require pharmacies to report errors. We recommend Congress pass a bill mirroring the Illinois Pharmacy Practice Act to improve pharmacists’ working conditions and mandate data collection on medication errors nationwide.

scholarly journals Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Adam Sutherland ◽  
Denham L. Phipps ◽  
Stephen Tomlin ◽  
Darren M. Ashcroft
Keyword(s):  
Patient Safety ◽  
Medication Errors ◽  
Adverse Drug Events ◽  
Improve Patient Safety ◽  
Safety Issue ◽  
Cochrane Library ◽  
Drug Related Problems ◽  
Prescribing Errors ◽  
Theoretical Understanding ◽  
The Uk

Abstract Background Problems arising from medicines usage are recognised as a key patient safety issue. Children are a particular concern, given that they are more likely than adults to experience medication-related harm. While previous reviews have provided an estimate of prevalence in this population, these predate recent developments in the delivery of paediatric care. Hence, there is a need for an updated, focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK, in order to support the development and targeting of interventions to improve medication safety. Methods Nine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to April 2019. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted. Results In all, 26 studies were included. There were no studies which specifically reported prevalence of adverse drug events. Two adverse drug reaction studies reported a median prevalence of 25.6% of patients (IQR 21.8–29.9); 79.2% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors (median prevalence 6.5%; IQR 4.7–13.3); of which, the median rate of dose prescribing errors was 11.1% (IQR 2.9–13). Ten studies reported on administration errors with a median prevalence of 16.3% (IQR 6.4–23). Administration technique errors represented 53% (IQR 52.7–67.4) of these errors. Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 23% (Range 20.1–46) of prescribed medication; 70.3% (Range 50–78) were classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors. Conclusions Children are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm,, there is a need for a deeper theoretical understanding of paediatric medication systems to enable more effective interventions to be developed to improve patient safety.

scholarly journals Likelihood of reporting medication errors in hospitalized children: a survey of nurses and physicians

2017 ◽  
Vol 9 (3) ◽  
pp. 179-192 ◽  
Author(s):  
Rikke Mie Rishoej ◽  
Jesper Hallas ◽  
Lene Juel Kjeldsen ◽  
Henrik Thybo Christesen ◽  
Anna Birna Almarsdóttir
Keyword(s):  
Patient Safety ◽  
Medication Errors ◽  
Healthcare Professionals ◽  
Incident Reporting ◽  
Hospitalized Children ◽  
Peer Reporting ◽  
Learning Potential ◽  
Nurses And Physicians ◽  
Peer Report ◽  
Reporting Rates

Background: Hospitalized children are at risk of medication errors (MEs) due to complex dosage calculations and preparations. Incident reporting systems may facilitate prevention of MEs but underreporting potentially undermines this system. We aimed to examine whether scenarios involving medications should be reported to a national mandatory incident reporting system and the likelihood of self- and peer-reporting these scenarios among paediatric nurses and physicians. Methods: Participants’ reporting of MEs was explored through a questionnaire involving 20 medication scenarios. The scenarios represented different steps in the medication process, types of error, patient outcomes and medications. Reporting rates and odds ratios with 95% confidence interval [OR, (95% CI)] were calculated. Barriers to and enablers of reporting were identified through content analysis of participants’ comments. Results The response rate was 42% (291/689). Overall, 61% of participants reported that scenarios should be reported. The likelihood of reporting was 60% for self-reporting and 37% for peer-reporting. Nurses versus physicians, and healthcare professionals with versus without patient safety responsibilities assessed to a larger extent that the scenarios should be reported [OR = 1.34 (1.05–1.70) and OR = 1.41 (1.12–1.78), respectively]; were more likely to self-report, [OR = 2.81 (1.71–4.62) and OR = 2.93 (1.47–5.84), respectively]; and were more likely to peer-report [OR = 1.89 (1.36–2.63) and OR = 3.61 (2.57–5.06), respectively]. Healthcare professionals with versus without management responsibilities were more likely to peer-report [OR = 5.16 (3.44–7.72)]. Participants reported that scenarios resulting in actual injury or incidents considered to have a learning potential should be reported. Conclusion: The likelihood of underreporting scenarios was high among paediatric nurses and physicians. Nurses and staff with patient safety responsibilities were more likely to assess that scenarios should be reported and to report. Incidents with actual injury or learning potential were more likely to be reported. The potential for improving reporting rates involving MEs seems high.

Use of Acupuncture in Hospices and Palliative Care Services in the Uk

2013 ◽  
Vol 31 (1) ◽  
pp. 16-22 ◽  
Author(s):  
Graham Leng
Keyword(s):  
Palliative Care ◽  
Healthcare Professionals ◽  
Response Rate ◽  
Evidence Base ◽  
Specialist Palliative Care ◽  
Online Questionnaire ◽  
Care Services ◽  
Palliative Care Services ◽  
Potential Benefits ◽  
The Uk

Purpose The aim of the present work was to evaluate the availability of acupuncture in UK hospices and specialist palliative care services and to identify any barriers to the use of acupuncture in these settings, to determine the characteristics of available acupuncture services and of practitioners providing acupuncture, and to determine awareness of the evidence base for the use of acupuncture in palliative care. Methods An online questionnaire with an invitation to participate was circulated by email to 263 hospices and specialist palliative care services in the UK. Results A response rate of 54% was obtained. Acupuncture was provided by 59% of services that responded. In general, small numbers of patients receive acupuncture as part of their palliative care treatment as inpatients, day patients or outpatients. Most practitioners were regulated health professionals who had received a Western-style training in acupuncture and used a Western-style medical acupuncture approach. Where acupuncture was not available the commonest reason given was the lack of a suitable practitioner. Most agreed that if funding and a suitable practitioner were available, acupuncture would be a useful addition to their service. The level of awareness of specific types of evidence supporting the use of acupuncture in palliative care was low, but most respondents were aware that some evidence existed. Conclusions There is a need to increase training in acupuncture for healthcare professionals working in palliative care. There is also a need to raise awareness of the potential benefits to patients and the evidence base supporting the use of acupuncture in palliative care.

5 Standard iv infusion concentration in paediatric and neonatal units: a national survey

2018 ◽  
Vol 103 (2) ◽  
pp. e2.45-e2
Author(s):  
Nanna Christiansen
Keyword(s):  
Patient Safety ◽  
National Survey ◽  
Response Rate ◽  
Improve Patient Safety ◽  
National Standards ◽  
List Type ◽  
National Patient Safety Agency ◽  
National Patient ◽  
National Consensus ◽  
The Uk

AimThe National Patient Safety Agency in the UK has advocated the use of standard concentration (SC) infusions to improve patient safety and care.1 National standards have been adopted for infusions in the adult critical care setting however practice in paediatric and neonatal settings still varies and presents a challenge.2,3 This study is part of a multi-professional collaborative working towards a national consensus on SC infusions in paediatric and neonatal care. The study aims to explore the practice of standardised concentration usage for Intravenous (IV) infusions in paediatric and neonatal units in the UK, specifically:How many units use standardised concentration for IV infusions.Evaluate the variation and overlap of continuous IV infusion concentrations in practice.Assess what devices are used to administer these infusions.How standardised infusions are provided.MethodThe study used a quantitative descriptive survey design via an online self-administered questionnaire. Paediatric and neonatal intensive care units in the UK were surveyed through pharmacy, nursing, and medical networks to describe current practice. Data was collected for 25 days and analysed using SPSS.ResultA total of 194 NICUs and 39 PICUs were surveyed. Responses were received from 71 units: NICU 46 (65%); PICU 17 (24%) and 8 other (11%), giving an overall response rate of 30.5%.Twenty-eight units (40%) have established SC for IV infusions, 18 units provided information on presentation of SC infusions. Forty-six different medication infusions were standardised. Considering the differences in concentration, weight-bands, diluents, volume and presentation, there were 273 variations for these drugs. Taking only the concentration into account, there were 137 variations presented. The average number of variations per medication was 3 (range 1 to 14).15 units (53.6%) use ‘smart’ pumps for administration of SC infusions and 3 (10.7%) use other computer software for infusion rate calculations. Infusions are most commonly prepared on wards (81.3%) or in pharmacy (12.3%).ConclusionThe study is limited by the response rate; however the results suggest that 59% of paediatric and neonatal units in the UK use conventional weight-based methods for IV infusions. A third of units have established some SC with a wide variation of concentrations in this sample. Just over half of the units use ‘smart’ pump technology and over three quarters of SC infusions are prepared on the ward.Further data collection is required to acquire a fuller picture of SC infusions used in UK PICUs and NICUs. This data can then be used as the basis of a national consensus statement on SC infusion, facilitating adoption across the NHS.ReferencesNPSA Patient Safety Alert 20: Promoting safer use of injectable medicines2007. London: The National Patient Safety Agency.MacKay MW, Cash J, Farr F, et al. Improving paediatric outcomes through intravenous and oral medication standardisation. J Pediatr Pharmacol Ther2009;14:226–35.Phillips MS, Standardising IV. Infusion concentrations: National survey results. Am J Health Syst Pharm2011;68:2176–82.

scholarly journals Protocol for a non-randomised feasibility study evaluating a codesigned patient safety guide in primary care

BMJ Open ◽  
2021 ◽  
Vol 11 (1) ◽  
pp. e039752
Author(s):  
Rebecca L Morris ◽  
Kay Gallacher ◽  
Mark Hann ◽  
Carly Rolfe ◽  
Nicola Small ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Health Service ◽  
Healthcare Professionals ◽  
Patient Empowerment ◽  
Service Utilisation ◽  
Two Phase ◽  
Ethical Approval ◽  
General Practices ◽  
The Uk

IntroductionPatients and carers should be active partners in patient safety with healthcare professionals and be empowered to use personalised approaches to identify safety concerns and work together to prevent them. This protocol paper details a study to examine the feasibility of a multicomponent intervention to involve patients and/or carers in patient safety in primary care in the UK.Methods and analysisThis is a two-phase, non-randomised feasibility mixed methods pragmatic study of a patient safety guide for primary care (PSG-PC). 8 general practices will recruit 120 patient and/or carer participants. All patient and/or carer participants will receive the PSG-PC. It will examine the feasibility and acceptability of the PSG-PC in primary care settings in patients aged 18 years or older who attend appointments at general practice with health professionals four or more times per year as either patients or carers. It will identify secondary outcomes for improving patient safety, health status and patient empowerment, and reducing health service utilisation over 6 months between baseline and 6-month follow-ups. The findings will inform whether a main effectiveness trial is feasible and, if so, how it should be designed, and how many patients and practices will be needed. The study will be undertaken between January 2020 and September 2021.Ethics and disseminationEthical approval was obtained from the National Health Service London-West London and Gene Therapy Advisory Committee Research Ethics Committee (reference: 19/LO/1289). Research findings will be disseminated with participating general practices and shared in a range of different ways to engage different audiences, including presenting at international and national conferences, publishing in open-access, peer-reviewed journals and facilitating dissemination workshops within local communities with patients, carers and healthcare professionals.Trial registration numberISRCTN90222092.

Risk management: have we got it right?

2011 ◽  
Vol 2 (1) ◽  
pp. 14-19
Author(s):  
John Tiernan
Keyword(s):  
Risk Management ◽  
Patient Safety ◽  
Healthcare Professionals ◽  
Management Strategies ◽  
Risk Management Strategies ◽  
The Subject ◽  
The Uk

The subject of risk management and patient safety is common in the newspapers and other forms of media in 2010. The increasing publicity surrounding professional error is not just confined to the UK. Healthcare professionals are under increased scrutiny and different risk management strategies are required to those that existed previously. This article suggests some key principles and strategies to help dental healthcare professionals reduce their risk of a professional challenge.

scholarly journals Acceptability and use of glaucoma virtual clinics in the UK: a national survey of clinical leads

2018 ◽  
Vol 3 (1) ◽  
pp. e000127 ◽  
Author(s):  
Patrick J G Gunn ◽  
Joanne R Marks ◽  
Leon Au ◽  
Heather Waterman ◽  
Paul G D Spry ◽  
...  
Keyword(s):  
Patient Safety ◽  
Usual Care ◽  
National Survey ◽  
Lower Risk ◽  
Response Rate ◽  
Model Of Care ◽  
Patient Acceptability ◽  
Risk Patients ◽  
The Uk ◽  
Question Survey

ObjectiveThe purpose of this paper is to describe the findings of a national survey that aimed to estimate the proportion of Hospital Eye Service (HES) units using glaucoma virtual clinics, to determine how these services differ and to gauge clinicians’ views and opinions on the safety and acceptability of this model of care compared with usual care.Methods and analysisThis 12-question survey was disseminated nationally to 92 clinical lead consultant ophthalmologists using SurveyMonkey.ResultsThe response rate was 45.7%. There were 21 out of the total 42 respondents (50.0%) who were based at an NHS Trust where glaucoma virtual clinics were already being used and a further 9 (21.4%) were planning to establish one. Clinical leads largely rated efficiency and patient safety to be at least equivalent to usual care (92.9%) and 81.0% perceived glaucoma virtual clinics to be acceptable to patients. The main reasons for not running glaucoma virtual clinics were insufficient staff (71.4%) and inadequate space (47.6%). The majority of those running virtual clinics used this model of care for ‘lower risk’ patients such as ocular hypertensives (90.5%) and glaucoma suspects.ConclusionGlaucoma virtual clinics are employed by a large proportion of HES units, with many seeking to develop such services. Clinical leads largely rate efficiency, patient safety and the perception of patient acceptability to be at least equivalent to usual care.

Sign in / Sign up

Export Citation Format

Share Document