Which non-technical skills do junior doctors require to prescribe safely? A systematic review

January 27, 2016

Source:  British Journal of Clinical Pharmacology

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Date of publication:  November 2015

Publication type:  Systematic review

In a nutshell:  The aim of this review was to develop a prototype non-technical skills (NTS) taxonomy for safe prescribing, by junior doctors, in hospital settings.  As a result of this research, a prototype taxonomy of relevant categories (situational awareness, decision making, communication and team working, and task management) and elements was constructed.  This prototype will form the basis of future work to create a tool that can be used for training and assessment of medical students and junior doctors to reduce prescribing error in the future.

Length of publication:  12 pages


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


How to make medication error reporting systems work – Factors associated with their successful development and implementation

September 30, 2015

Source:  Health Policy 119/8 pp. 1046-54.

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Date of publication:  August 2015

Publication type:  Journal article

In a nutshell:  This study explored medication error reporting (MER) systems in different healthcare contexts. Sixteen medication safety experts in sixteen countries responded to a descriptive online questionnaire. Several factors related to the national context of MER systems, i.e., the operational environment, were identified to impact successful development and implementation of these systems. The authors concluded that operational environments of MER systems must be constructed to support functionality of these systems, and need to be improved in many countries.

Length of Publication:  9 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


Patient safety alert to improve reporting and learning of medication and medical devices incidents

April 30, 2014

Source:  NHS England

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Date of publication:  March 2014

Publication type:  News item

In a nutshell:  Two patient safety alerts have been issued by NHS England and the Medicines and Healthcare products Regulatory Agency (MHRA) to help healthcare providers increase incident reporting for medication errors and medical devices. The alerts will improve data report quality and will see the establishment of national networks to maximise learning and provide guidance on minimising harm in relation to these types of incidents. The alerts call on large healthcare provider organisations across a range of healthcare sectors and healthcare commissioners to identify named leaders in both medication and medical device safety roles. The leaders will be supported by two new national networks for medication and medical device safety.

Length of Publication:  1 web page


Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study.

February 25, 2013

Source:  Research in Social and Administrative Pharmacy Vol/iss 9/1 pp.80-89

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Date of publication:  January 2013

Publication type:  Journal article

In a nutshell:  In England, hospital pharmacists said that medication errors are common and that they are often not reported. Error reporting forms are thought to be cumbersome and time consuming. It could be useful to simplify reporting forms, ensure staff are praised for reporting and make sure that any issues are addressed quickly so that staff feel that reporting is worthwhile.

Length of Publication:  10 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.


Patient safety: learning from Europe

July 30, 2012

Source:  The Health Foundation

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Date of publication: May 2012

Publication type: Blog entry

In a nutshell:  This is a joint action looking at lessons that can be learned, and passed on, between the different countries in Europe.  An example of this would be the level of understanding and concern there is in the UK with healthcare acquired infection, while in Spain the high priority there is a high public awareness of medication errors and a need to reduce risk in this area.


Call for clarity over replacement for patient safety organisation

November 3, 2011

Source:  Nurs Stand. 2011 Aug 24-30;25(51):11

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Date of publication: August 2011

Publication type:  News item

In a nutshell:  The government is being asked to clarify who will carry out the National Patient Safety Agency’s work after the body is axed. There is a proposal in the Health and Social Care Bill to abolish the agency next year. The NHS Commissioning Board would take responsibility for reporting and learning from patient safety incidents in England.

Length of publication:  1 web page

Some important notes:  This article is available in full text to all NHS Staff using Athens, for more information about accessing full text follow this link to find your local NHS Library


Keeping patients safe when they transfer between care providers

July 28, 2011

Source: Royal Pharmaceutical Society

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Date of publication: July 2011

Publication type: Guidance

In a nutshell: This guidance looks at the one of the risks to patient care when the patient is transferred between health care providers.   This risk is the miscommunication or unintended change to medications.  The guidance looks at ways to reduce this risk and reduce preventable incidences.

Length of publication: 11 pages

Acknowledgements:  Kings Fund blog


Can teaching medical students to investigate medication errors change their attitudes towards patient safety?

May 28, 2011

Source: BMJ Quality & Safety  2011;20:319-325

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Date of publication: February 2011

Publication type: Journal Article

In a nutshell: This article considers if giving medical students a basic knowledge of common medication errors before they start to see patients in hospital can reduce the chance of them making mistakes. The study was  carried out during a paediatric rotation at the Johns Hopkins Children’s Center.

Length of publication: 8 pages

Some important notes: This article is available in full text to all NHS Staff using Athens, for more information about accessing full text follow this link to find your local NHS Library

Acknowledgement: The British Journal of Healthcare Computing & Information Management


Detecting harm following paracetemol overdose – Signal

January 28, 2011

Source: National Reporting and Learning Service

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Date of publication: October 2010

Publication type: Signal

In a nutshell: This is a notification of the key risks involved when patients have been given an overdose of paracetemol.  It looks at reducing the risk of harm to these patients.

Length of publication: 1 webpage

Some important notes: All signal reports are available from the NPSA website.

Acknowledgement: National Patient Safety Agency


Clinicans warned of the dangers of loading doses of drugs

December 22, 2010

Source: National Patient Safety Agency

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Date of publication: 25 November 2010

Publication type: News Item

In a nutshell:  The NPSA has issued a new Rapid Response Report (RRR) in a bid to reduce the possibility of harming or causing death through overloading syringes with medicine.   

Length of publication: 1 webpage