Everyone will, at some point in their lives, take medication to prevent or treat illness. Medication has changed human ability to live with disease and generally increased lifespan.
However, some medications do sometimes cause serious harm if taken incorrectly, monitored insufficiently, or is the result of an error, accident, or miscommunication.
Patient safety experts have found that mistakes in health care are usually due to flawed or dysfunctional systems, its processes and procedures, and rarely due to neglect. The inevitable consequential errors also apply to medication harm.
A medication error has been defined by the United States’ National Coordinating Council for Medication Error Reporting and Prevention as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer”.
All medication errors are potentially avoidable. They can be greatly reduced or even prevented by improving the systems and practices of medication, including ordering, prescribing, dosing, preparation, dispensing, administration, timing, and monitoring.
Scale Of Medication Harm
Unsafe medication practices and medication errors are a leading cause of avoidable harm in health care systems globally. The scale and nature of this harm differs between countries.
The annual global cost associated with medication errors has been estimated at US$42 billion. Patients in low-income countries experience twice as many disability-adjusted life years lost due to medication harm than those in high-income countries.
Medication errors occur when weak medication systems and/or human factors like fatigue, poor environmental conditions, or staff shortages affect prescribing, transcribing, dispensing, administration, and monitoring practices, which can then result in severe harm, disability, and even death.
Errors occur most frequently during administration, however, there are also risks at different stages of the medication process.
Whenever medication harm is mentioned, my memory goes back to an incident when I was a medical officer in a surgical unit. I had performed a splenectomy on a 15-year-old boy after he sustained a ruptured spleen following a road traffic accident.
On the third post-operative day, he was prescribed chloroquine for malaria, which he contracted when hospitalised. The next day, he died from chloroquine toxicity following the administration of 10 times the prescribed dose. Following an inquiry, the staff responsible was transferred to the medical ward.
World Patient Safety Day 2022
World Patient Safety Day is observed by member states of the World Health Organization (WHO) on September 17, 2022. The theme for 2022 is “Medication Without Harm”, which is the third WHO Global Patient Safety Challenge (GPSC). The previous two Global Patient Safety Challenges were “Clean Care Is Safer Care” and “Safe Surgery Saves Lives”.
The vision of the 2022 GPSC is to reduce the level of severe, avoidable harm related to medications by 50% over the next five years globally.
Objectives Of 2022 Campaign
The four objectives of the 2022 World Patient Safety campaign are:
- Raising global awareness of the high burden of medication-related harm due to medication errors and unsafe practices and advocating for urgent action to improve medication safety.
- Engaging key stakeholders and partners in the efforts to prevent medication errors and reduce medication-related harm.
- Empowering patients and families to be actively involved in the safe use of medication.
- Scaling up implementation of the WHO Global Patient Safety Challenge, which is “Medication Without Harm”.
There are key messages in the 2022 GPSC for patients, families and the public, health care professionals, health care leaders and facility managers, and policymakers and programme managers.
Patients, Families And General Public
- When prescribed any medication, check with your health care professional that you have been given all the information needed to take it safely. Follow the Know, Check, Ask actions, i.e. Know your medication, Check that you have the right patient, medicine, route, dose, time, and Ask your patient if they understand the instructions.
- Keep an updated list of all the medications you take, including traditional medicines, and share it with your treating health care professional.
- Take medications as recommended by your health care professional.
- Use the five moments for medication safety tool, i.e. Starting a medication, Taking a medication, Adding a medication, Reviewing a medication, and Stopping a medication, to ensure safety while taking any medication.
- Be aware of the potential side effects of your medications.
- Store medications as indicated and check the expiration date regularly.
- Raise any concerns about your medications with your health care professional.
Health Care Professionals
- Keeping skills in safe medication practices up to date.
- Engage patients through shared decision-making using tools such as the five moments for medication safety and implement actions related to the Know, Check, Ask campaign.
- Provide clear and full medication-related information to all members of the clinical team throughout the process of care.
- Report medication safety incidents and share and apply lessons learned with your team and patients when possible.
- Be mindful of situations where risk from medications is high and ensure safety measures are followed.
- Mentor new members of your team on safe medication systems and practice.
Health Care Leaders And Facility Managers
- Designate a focal point and a multidisciplinary team to develop processes to ensure medication safety in the facility,
- Develop and implement standard operating procedures for safe medication use, taking into account the risk of human error.
- Make sure there are sufficient staff to cover patients’ medication needs.
- Provide opportunities to train health professionals on safe medication use.
- Operationalise a patient safety incident reporting and learning system, including medication safety incidents (medication errors and related harm).
- Create a safety culture where health professionals are able to raise safety concerns related to medications.
- Prioritise action in areas where most medication-related harm occurs, such as high-risk situations, transitions of care, and polypharmacy.
- Put in place strategies to reduce the risk of medication errors, such as double-checking, patient engagement, and using information technology to improve processes.
Policymakers And Programme Managers
- Ensure medication safety is addressed at all levels/settings in the health care system.
- Assess the burden of medication-related harm in your country.
- Integrate medication safety into every stage of patient care.
- Co-design and implement medication safety programmes with stakeholders, including patients and public.
- Establish a patient safety incident reporting and learning system, including medication safety incidents (medication errors and related harm).
- Monitor progress and evaluate the impact of medication safety programmes.
- Launch the Know, Check, Ask Campaign as the medication safety campaign across the country.
The WHO’s Global Patient Safety Challenge strategic framework depicts the four domains of the challenge: patients and the public, health care professionals, medicines, and systems and practices of medication. The framework describes each domain through four subdomains.
The three key action areas — namely polypharmacy, high-risk situations, and transitions of care — are relevant in each domain, and thus form an inner circle. This is summarised in the chart below:
Take Home Message
Everyone has a role in reducing the incidence of medication harm. Patients and the public have a critical role to play to ensure that they do not become the subjects of medication harm.
Dr Milton Lum is a Past President of the Federation of Private Medical Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.