Patient safety alert – Support to minimise the risk of distress and death from inappropriate doses of naloxone

November 25, 2015

Source:  NHS England

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Date of publication: October 2015

Publication type: Safety alert

In a nutshell: A patient safety alert has been issued by NHS England to support providers of NHS funded care to minimise the risk of distress and death caused by inappropriate doses of naloxone.  The new ‘Stage 2: Resource’ alert highlights a number of resources now available to help providers ensure their local protocols and training related to naloxone reflect best practice.

Length of Publication: 1 webpage


Reducing unacceptable missed doses: pharmacy assistant-supported medicine administration

November 25, 2015

Source: International Journal of Pharmacy Practice 23/5 pp. 327-332

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Date of publication: October 2015

Publication type:  Journal article

In a nutshell: The potential harm from omitted and delayed medicines for hospital inpatients was highlighted by the National Patient Safety Agency (NPSA). This study aimed to assess the impact on omitted doses when medicine administration was supported by pharmacy assistants (PAs).  The authors concluded that PA-supported medication rounds can significantly reduce the rate of omitted doses. This study provides evidence for a potential solution to the problem of omitted doses for hospital inpatients.

Length of Publication:  7 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Factors contributing to registered nurse medication administration error: a narrative review

February 20, 2015

Source:  International Journal of Nursing Studies 52/1 pp. 403-20

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Date of publication:  January 2015

Publication type:  Journal article

In a nutshell: The authors explored the factors contributing to medication administration incidents amongst registered nurses. A number of factors, including the environment and characteristics of the nurse, were found to influence medication administration incidents. In terms of environment, clinical workload and work setting were important. In terms of nurse characteristics, nurses’ lived experience of work and their demographics were significant. More studies have focused on environmental issues than on how personal characteristics may contribute to incidents. Any inter-relationship between factors was not explored.

Length of Publication:  17 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012

August 27, 2014

Source:  Anaesthesia 69/7 pp. 735-45

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Date of publication:  July 2014

Publication type:  Journal article

In a nutshell:  One of the key tools promoted for improving patient safety in healthcare is incident reporting. The authors of this study analysed 2238 patient safety incidents involving medications submitted from up to 29 critical care units in the North West of England every year between 2009 and 2012. 452 of the incidents led to harm to patients. The most commonly reported drugs were noradrenaline, heparins, morphine and insulin. The administration of drugs was the stage where incidents were most commonly reported. This was also the stage most likely to harm patients. The authors conclude that quality improvement initiatives could improve medication safety in the units studied.

Length of Publication:  11 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Administration of medicines – the nurse role in ensuring patient safety.

March 27, 2013

Source:  Br J Nurs. Vol/iss 22/1 pp. 32-5

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Date of publication:  January 2013

Publication type:  Journal article

In a nutshell:  The importance of drug administration and some of the key legislation that relates to it is explored in this paper. The responsibility of qualified nurses and student nurses in this area is discussed. The authors look at the concept of informed consent and what that means in the health care setting. The importance of the safe administration of medicines to patients is emphasised.

Length of Publication:  4 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.


Errors during the preparation of drug infusions: a randomized controlled trial.

January 30, 2013

Source:  Br J Anaesth, vol/iss 109/5 pp.729-34.

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Date of publication:  November 2012

Publication type:  Journal article

In a nutshell:  The authors investigated the degree and frequency of dose errors and treatment delays made as a result of preparing drug infusions at the bedside, instead of using pre-filled syringes. Although there is a financial implication, providing drug infusions in syringes pre-filled by pharmacists or pharmaceutical companies would reduce medication errors and treatment delays, and improve patient safety.

Length of Publication:  6 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.


Trust launches Green Bag initiative to improve patient safety

July 30, 2012

Source: Great Western Hospitals NHS Foundation Trust

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Date of publication: June 2012

Publication type:  News item

In a nutshell:  Pharmacy Staff have launched an initiative to enable patients to keep their medication beside them at all times.  This ensures consultants and doctors have more complete information on what the patient is taking.  This can reduce the delay in patients receiving the correct medication when they are in hospital.  It can also be cost effective as it reduced the need for Pharmacy staff to re-supply medicines patients already have at home.