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Posted 27 Nov 2014 in Medication

The Health Quality & Safety Commission has published two in a series of ‘one step’ activities designed to help clinicians identify risks and change systems and practices relating to high-risk medicines.

The activities are part of the Open campaign focus on reducing harm from high-risk medicines, which can cause harm and even death.

Each one step focuses on different issues relevant to safety for some high-risk medicines. Some focus on clinical audit of prescriptions and are particularly relevant to resident medical officers; others focus on guidelines and patient information, and might be particularly relevant to quality and risk.

The one steps each pose 4–6 questions designed to:

  • help clinicians check some aspect of the safety system for a high-risk medicine in any area of work, whether on a ward, across a whole hospital or in another care setting
  • stimulate discussion about the system and what changes could be made to reduce the risk of harm from those medicines.

The one steps can be completed by any clinician.

The two one steps published on the Open website at are on:

  • potassium chloride infusion – review of prescriptions (concentration and fluid)
  • concentrated potassium ampoules – check for safe storage and management.

Several more on aspects of insulin prescribing, dispensing, management and administration are being developed and tested.

A competition for clinicians to develop their own one steps is planned. Further information will be available soon.