Introduction of a standard revised medication chart significantly reduced the frequency of prescribing errors, improved ADR documentation and decreased the potential risks associated with warfarin management. The standard chart has enabled uniform training in medicine management.

Objectives: To develop a standard for safe patient referral from emergency medicine (EM) staff to hospital inpatient specialities; to audit adherence to that standard, and from this audit, to identify potential risk areas in this aspect of patient care; to make recommendations for reducing such risks; and to implement those recommendations. Method: A standard was introduced and practice was compared to that standard using a telephone questionnaire.Results: Many problems arising at referral were identified. From these, recommendations were made for improvements. At the base hospital, those recommendations were implemented. These potential pitfalls are highlighted, together with strategies for improving safe handover of patient care. The discussion includes a review of the literature on safe handovers, which underpins both the importance of this subject and our findings and recommendations. Conclusions: Referral is an important skill for many doctors, particularly those in EM. It requires teaching and practice. The corollary to this is that education in this arena is also essential for those receiving referrals, to ensure smooth communication and safe systems of handover for patients. Handover of patients from doctor to doctor or from one team to another has been identified as a high risk area. Appropriate communication is essential to ensure the safe ongoing care of patients.1-4 For doctors working in emergency medicine (EM) this communication is usually in the form of referrals to medical staff working for inpatient specialities. One of the skills integral to efficient working in EM is the art of referral. In this study, we explored the factors influencing EM doctors' referring habits.A literature search revealed much work on aspects of emergency admissions. Relevant features from these papers are explored in the discussion. However, no formal guidelines were identified on the subject of referrals. As a basis for this audit, we took as our the standard that:''The decision to refer to a particular specialty should be based on clinical evaluation by the emergency medicine clinicians, and current local practices''.Discussion within our department suggested that other factors, such as the approachability and helpfulness of the receiving specialist, were important. In an attempt to determine what additional factors influence referrals, an audit was carried out questioning EM junior doctors (senior house officers (SHOs), specialist registrars (SpRs), and staff grades (SGs)) about their referral experiences. METHODSA questionnaire was developed (table 1). This was piloted on 30 junior doctors in a 2 week period in December 2001. A further 42 doctors were contacted in a 2 week period in May 2002. Two researchers, (CM and KF) filled in the questionnaires, in person or by telephone. The timing was such that the doctors interviewed could be expected to have had several months of EM experience.Subject selection was by either telephoning or attending departments, and speaking to those doctors on duty at that time. FindingsTh...

National implementation of a standard medication chart is possible. Similar reduction in the rate of prescribing errors can be achieved in multiple sites across one country. The consequent benefits for patient care and training of staff could be significant.

Community associated methicillin resistant Staphylococcus aureus (CA-MRSA) is an emerging pathogen typically associated with skin and soft tissue infection, with occasional reports of fatality in previously healthy children and young adults. We report a case of invasive CA-MRSA and highlight the potential impact of such infections on empirical treatment of staphylococcal infections.A n 11 year old boy of African origin was admitted to his local hospital with left hip pain, fever, and an inability to weight bear (day 1). The day before, he had fallen on to his left hip while playing football; his symptoms started soon afterwards. He had no significant past medical history; four months previously he had moved to the UK. At presentation he was unwell and febrile (40.1˚C) with a high C-reactive protein (CRP) of 104 mg/l. An ultrasound scan of his left hip was inconclusive. The pain extended to his left inguinal region and testis; he was treated with intravenous flucloxacillin and cefotaxime for epididymo-orchitis, and ibuprofen for pain relief. He remained febrile over the next four days and the pain spread to his left thigh and loin. MRSA was isolated from the single blood culture bottle taken at presentation. He developed acute renal failure on day 5 (urea 20.3 mmol/l, creatinine 396 mmol/l), which was treated with intravenous fluids without improvement; he was transferred to our renal unit. MRSA was identified again, from a blood culture drawn on day 2, and vancomycin was added to his therapy. He had no skin lesions. He now described right sided pleuritic chest pain. Examination revealed a right sided pleural rub and coarse crackles. A chest radiograph showed right basal consolidation with a pleural effusion. An MRI scan identified osteomyelitis of the left pubic ramus with a subperiostial collection, which was drained and irrigated surgically. MRSA was cultured from the intra-operative periosteum and pus specimens and histology confirmed acute osteomyelitis. His antibiotics were rationalised to vancomycin and oral rifampicin (600 mg once daily). Unusually, the MRSA isolates were susceptible in vitro to erythromycin and ciprofloxacin. He remained febrile (temperatures >38˚C) over the next six days, his CRP remained raised, and he developed a soft systolic murmur. Transthoracic echocardiography did not show vegetations and the murmur resolved. Pleural fluid aspirated on day 12 was purulent but sterile. His renal failure, which improved, was attributed to interstitial nephritis, secondary to b-lactams and/or ibuprofen. On day 16 his fever and CRP (35 mg/l) were settling. He was discharged to his local hospital on vancomycin and rifampicin.The MRSA susceptibility pattern and the epidemiology suggested that this might be a community associated strain. Genotypic analyses (including pulsed field gel electrophoresis, detection of the Panton-Valentine Leukocidin (PVL) genes, exfoliative toxin D gene, and SCCmec type IVc) confirmed this isolate to be representative of the sequence type 80 clonal lineage, the so called Eur...

Aim:To assess the ability of nurses to identify medication errors and apply strategies to prevent adverse drug events. Method: This was a prospective study of the incidence of error detection in simulated medication scenarios at a teaching hospital. All newly employed registered nurses (n = 591) were asked to administer medications in six scenarios containing errors with potential for patient harm. Feedback was provided to participants at the end of each scenario. The main outcome measures were: self-reported incidence of detection of errors and modification of practice in accordance with knowledge, knowledge of concept but error not detected, or the error being a new concept. Results: 63 to 85% of nurses reported that they would have detected the error and taken appropriate action; 11 to 30% had some concept of the error but would not have detected it; and for 2 to 7% the error was a new concept. 32% could identify the errors in all six scenarios and initiate appropriate action. Conclusion: In this study, nurses frequently failed to detect medication errors. Practical medication risk awareness training, improvements in the safety of medication systems and pharmacist review of medication are of paramount importance.