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NICE NPSA medicines reconciliation adults hospital10258NPSA04612/1/2007 7:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This joint guidance with NICE addresses practices to reduce medication errors which occur most commonly on transfer between care settings and on admission to hospital. 7/7/2015 9:22:42 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Promoting safer use of injectable medicines10260NPSA0523/28/2007 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)Research evidence also indicates that the incidence of errors in prescribing, preparing and administering injectable medicines is higher than for other forms of medicine. Using data from the NRLS and other evidence, the NPSA has identified a number of latent system risks and is making recommendations that can make the use of injectable medicines safer. A number of those recommendations plus additional actions to reduce risk are provided in this alert. As well a summary of data from January 2005 to June 2006 revealing the level of risk associated with injectable medicine use is provided in a series of tables that identify the following: - type of incident reported - degree of harm - stage of the medication process at which the incident occurred - type of injectable medication incident - Comments: Supporting material includes: Risk assessment tool, Workforce competency statements and Standard operating procedures.7/7/2015 9:22:42 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Reducing the risk of hyponatraemia when administering intravenous infusions to children10261NPSA0573/28/2007 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This Patient Safety Alert advises healthcare organisations how to minimise the risks associated with administering intravenous infusions to children. The development of fluid-induced hyponatraemia (a plasma sodium of less than 135mmol/L) in the previously well child undergoing elective surgery or with mild illness may not be well recognised by clinicians and may be worsened by the administration of hypotonic solutions. Actions to reduce risk are provided and further discussed in the source document along with intravenous fluid guidelines. 7/7/2015 9:22:42 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Risk of confusion between cytarabine and liposomal cytarabine (Depocyte)10262NPSA0596/18/2007 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This Rapid Response Report focuses on alerting staff involved in the preparation and administration of intrathecal cytarabine of the potential for confusion between two similar preparations of the drug -- cytarabine (standard form) and liposomal cytarabine (Depocyte®), the newer long-acting formulation. Possible confusion between the two licensed cytarabine products for administration by the intrathecal route can lead to: - over or under dosing due to the dose frequency of the two licensed cytarabine products being different; - induction of severe acute arachnoiditis due to the use of lyposomal cytarabine (Depocyte®) without concomitant administration of a steroid. Actions to reduce risk are provided.7/7/2015 9:22:42 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Risk of confusion between non-lipid and lipid formulations of injectable amphotericin10263NPSA0609/3/2007 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This Rapid Response Report focuses on alerting all healthcare staff involved in the use of intravenous amphotericin of the potentially lethal results if non-lipid and lipid formulations of the drug are confused. A contributing factor to the mix-up is that the dosage recommendations for these different amphotericin preparations range from 1 – 5mg/kg. Confusion between the different formulations of amphotericin products can lead to: - over or under dosing due to the different dose recommendations for each product; - patients experiencing potentially lethal side effects or sub-therapeutic doses. Actions to reduce risks of patient safety incidents are provided.7/7/2015 9:22:42 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Safer practice with epidural injections and infusions10265NPSA0653/28/2007 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This Patient Safety Alert focuses on the National Patient Safety Agency (NPSA) identified actions that can make administering epidural injections and infusions safer. The most common errors resulting have been wrong route errors where epidural medicines have been administered by the intravenous route, intravenous medicines have been administered by the epidural route and the wrong product selected, resulting in the wrong drug or dose being administered. The patient safety incidents presented highlight a number of risks related to epidural injections and infusions, including how the medicines and devices are labelled, stored and used. In addition, summary tables of the following, based on incidents reported to the NRLS from 1 January 2005 to 31 May 2006, are provided: - clinical outcome of epidural incidents, - types of epidural incidents, and - clinical areas reporting epidural incidents Actions to reduce risk of occurrence of these incidents are provided.7/7/2015 9:22:42 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Risks to haemodialysis patients from water supply (hydrogen peroxide)10272NPSA0349/20/2008 6:00:00 AMDeviceNational Health Service Commissioning Board (England and Wales)This Rapid Response Report outlines a cluster of patient safety incidents in one NHS trust where haemodialysis patients were re-admitted to the hospital 2-7 days after treatment with acute haemolysis (destruction of red blood cells leading to anaemia and risk of severe hyperkalemia). One patient with a history of severe cardiac problems died and four other patients with severe symptomatic anaemia required blood transfusion. Initial investigation by the trust revealed that silver stabilised hydrogen peroxide had been added the hospital water system to address water quality issues including legionella, the day before the treatment of these patients. The renal unit had not been informed beforehand of this change to the water to take appropriate steps to reduce harm to the patients with the addition of silver stabilised hydrogen peroxide. This Report highlights that clinical staff should be alert to signs of haemolysis, which are variable and may be acute (headache, weakness, tachycardia and breathlessness) or, milder symptoms of anaemia after treatment and also to signs of methaemoglobinaemia during dialysis where patients exhibit signs of cyanosis (turn blue) with a drop in oxygen saturation due to the inability of the red blood cells carrying capacity to maintain proper oxygenation. Recommended actions to reduce risk have been included in this Report.7/7/2015 9:06:57 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Clean hands save lives10273NPSA0389/2/2008 6:00:00 AMInfection ControlNational Health Service Commissioning Board (England and Wales)Significant gains have been made in highlighting the need for best practice in hand hygiene. This Patient Safety Alert highlights the continuing vigilance for proper hand hygiene of healthcare staff during patient care to reduce healthcare associated infections. Hands are a repository for microorganisms that can cause infection and healthcare staff in all healthcare settings have a great chance of transferring these as they move between patients, or different care activities for the same patient. Key points to remember are included in the Alert such as: the role of hand hygiene by healthcare staff in preventing and controlling infection, the point of care as the crucial moment for hand hygiene, the appropriate placement of alcohol handrub products, which hand hygiene products to use and when, the current recognised standard for hand hygiene products, and management of risks including ingestion, storage and skin irritation. Actions to reduce risk have also been included in the Alert. 7/7/2015 9:11:35 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Problems with infusions and sampling from arterial lines10274NPSA0507/28/2008 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This Rapid Response Report addresses patient safety incidents that can occur with use of arterial lines. Patient safety incidents include the wrong infusion fluid being delivered through the arterial line, a faulty sampling technique such as sampling blood glucose from lines with glucose running (and patient treated based on falsely high readings) and mis-selecting potassium chloride instead of sodium chloride 0.9% for injection. Contributing factors include look-alike labelling and packaging of intravenous infusion bags and inadequate checking before attachment. A particular risk is the need to cover the infusion with a pressure bag which obscures the label during use. Risks of confusion are increased when patients are transferred from other areas. Sampling errors include problems when taking and managing the samples, contamination by inadequate flushing and confusing arterial with venous lines. Actions to reduce risk are provided.7/7/2015 9:22:42 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Safety Strategies for Potassium Phosphates Injection10275ISMPC314/1/2006 7:00:00 AMMedicationInstitute for Safe Medication Practices Canada"The Bulletin describes safety issues with Potassium Phosphates Injection and provides recommendations for preventing related adverse events. The information focuses on the labeling, prescribing, preparation, and administration of potassium phosphates."7/7/2015 9:21:32 AMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse