Patient Safety Horizon Scanning Volume 4 Issue 12

Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

Source:  Drug Safety vol/iss 36/11 pp. 1045-1067

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Date of publication:  November 2013

Publication type:  Journal article

In a nutshell:  The causes of medication administration errors in hospital were examined in this article. Medication lapses were the most commonly reported medication administration errors, followed by mistakes-based on inaccurate knowledge or deliberate violations. Factors potentially leading to medication administration errors included inadequate written communication, problems with medicines supply and storage such as pharmacy dispensing errors and ward stock management, perceived high workload, problems with access to or functioning of ward equipment, patient availability or acuity, fatigue or stress amongst professionals and distractions during drug administration. Medication administration errors are influenced by multiple systems factors so managers and clinicians need to take a system-wide approach to minimise errors.

Length of Publication:  23 pages

Seeing it from Both Sides: Do Approaches to Involving Patients in Improving Their Safety Risk Damaging the Trust between Patients and Healthcare Professionals? An Interview Study

Source:  PLoS One vol/iss 8/11 pp.e80759

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Date of publication:  November 2013

Publication type:  Journal article

In a nutshell:  In this study, researchers from England examined the views of patients, families and professionals about patients being more involved in safety improvement. Patients, families and professionals were generally positive about the potential for patients to identify safety issues. There were some concerns about suspicion and mistrust. Patients were concerned about negative staff attitudes and unreceptiveness and professionals were worried about patients’ motives for questioning. A collaborative, mutually acceptable, approach to patient involvement in the promotion of safety improvement is required.

Length of Publication:  1 web page

Patient safety alert on placement devices for nasogastric tube insertion

Source:  NHS England

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Date of publication:  December 2013

Publication type:  News item

In a nutshell:  NHS England has issued a patient safety alert on the use of placement devices for inserting nasogastric tubes. Available from the Central Alerting System (CAS), this alert will ensure all hospitals and community services that use nasogastric tubes continue to follow previous guidance issued by the National Patient Safety Agency even when placement devices are used. It has been issued in response to two recently reported patient safety incidents.

Length of Publication:  1 web page

NHS England promises new and far reaching drive to improve patient safety

Source:  NHS England

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Date of publication:  November 2013

Publication type:  News item

In a nutshell:  In this news item, NHS England describes the important work it is leading on to improve the safety of patients as part of a co-ordinated response to the Francis Report. Action that NHS England has already taken includes launching the Friends and Family Test to gather patient feedback, and rolling out a new plan for nursing, midwifery and care staff – the 6Cs Compassion in Practice strategy. NHS England’s medical director, Professor Sir Bruce Keogh, has also carried out a review of the quality of care and treatment provided by 14 hospital trusts that are persistent outliers on mortality indicators.

Length of Publication:  1 web page

New milestone reached in NHS patient safety

Source:  NHS England

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Date of publication:  November 2013

Publication type:  News item

In a nutshell:  In this blog post, NHS England’s National Director for Patient Safety, Mike Durkin, discusses the tenth anniversary of the of the first incident reported on the National Reporting and Learning System (NRLS). The NRLS was set up in 2003 to encourage healthcare professionals to talk about errors, learn from them, and to be open and transparent with the patients and families affected by them.

Length of Publication:  1 web page

Experience-based co-design toolkit

Source:  The King’s Fund

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Date of publication:  November 2013

Publication type:  Toolkit

In a nutshell:  A new version of the experience-based co-design toolkit – a powerful and effective way to help service providers run and assess their own patient-centred care projects – has been launched. The toolkit incorporates learning and feedback from staff and patients involved in more than 60 EBCD projects, including an important adaptation, the accelerated form of EBCD.

Length of Publication:  1 web page