Image Source: WHO
Are medication errors one of the most frequently reported incident types in your hospital? What can be done to prevent medication errors? Is medication-related harm avoidable? According to the WHO, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care globally. Medication-related harm represents 50% of all preventable harm in medical care and remains a critical patient safety issue.
Against the backdrop of Covid-19 pandemic, ‘Medication Safety’ has been aptly selected as the theme for World Patient Safety Day (WPSD) 2022, with the slogan ‘Medication Without Harm’. This year’s campaign also provides a platform to reenergize the WHO Global Patient Safety Challenge: Medication Without Harm launched in 2017.
QUASR joins the WPSD campaign to promote awareness and urge all stakeholders to address medication safety as a priority in patient safety across all levels of healthcare.
Objectives of World Patient Safety Day 2022
The objectives of WPSD 2022 are as follow:
- 1. RAISE global awareness of the high burden of medication-related harm due to medication errors and unsafe practices, and ADVOCATE urgent action to improve medication safety.
2. ENGAGE key stakeholders and partners in the efforts to prevent medication errors and reduce medication-related harm.
- 3. EMPOWER patients and families to be actively involved in the safe use of medication.
- 4. SCALE UP implementation of the WHO Global Patient Safety Challenge: Medication Without Harm.
Source: WHO WPSD 2022
Important Factors that Influence Medication Errors
Medication errors occur when weak medication systems and human factors such as fatigue, poor environmental conditions or staff shortages, task, and the primary-secondary care interface affect the safety of the medication process. This can result in severe patient harm, disability and in some cases even death.
List of factors that influences the medication errors:
● Lack of therapeutic training
● Inadequate drug knowledge and experience
● Insufficient knowledge of patients record
● Overworked or fatigued healthcare professionals
● Physical and emotional health issues
● Poor communication between healthcare professionals and patients
● Lack of standardized policies, protocols and procedures
● Issues with physical work environments (eg: lightings, and ventilators)
● Complexity in naming of medicines, labeling and packaging
● Limited quality of communication with secondary care
● Distractions and interruptions by other staff or patients
What Can Organizations Do to Enhance Medication Safety?
All medication errors are potentially preventable. They can be greatly reduced by improving the systems and practices of medication prescribing, transcribing, dispensing, administration, and monitoring. A fundamental step in enhancing medication safety is that healthcare organizations must be familiar with the medications that are available to treat their patients. There are several ways to accomplish medication safety:
- ► Maintain up-to-date references of current medications and have those references available at the time the drug is prescribed.
- ► Proper container labels to help healthcare providers and patients select the right drug. If a drug is made in multiple strengths – e.g., 5 mg, 10 mg, and 25 mg, – the labels of those three containers should be easy to differentiate.
- ► In depth knowledge of potential interactions between a newly prescribed medication and other medications already being used by the patient, including non-prescribed medications and supplements, as well as treatments being considered.
- ► Recognize the potential risk of high-alert medications, those drugs that bear a heightened risk of causing severe patient harm if there is an error in the medication-use process.
- ► Electronic prescribing (also known as e-prescribing) refers to a prescriber’s ability to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy from the point-of-care
- ► Medication orders should be legible and must include the following components: name of the drug, dose, route of administration, frequency, reason or conditions under which the drug should be prescribed, and patient’s weight and age
- ► Engaging the patient in their own care may improve adherence, patient satisfaction, and also reduce opportunities for medication errors. This requires the concerted effort of all members of the medical team, both in and out of the hospital.
- ► Automated healthcare technologies are the greatest potential for dramatically reducing the incidence of harm caused by medication errors. Equally important is the fact that their effect depends on the success with which they are integrated into well-designed care processes.
- ► Maintain up-to-date references of current medications and have those references available at the time the drug is prescribed.
Priority Areas to Prevent Medication Errors
WHO has identified three key areas to focus on to protect patients from medication harm. Medication errors are more likely to occur in certain high-risk situations, when patients are using multiple drugs, and during transitions of care.
A. High-risk situations
The impact of medication errors is greater with treating inpatients in a hospital. This may be related to the more acute clinical situations in these settings and the use of more complex medications. Young children and the elderly people are more susceptible to its adverse effects. Medication errors in such scenarios often involve the administration of the wrong dose and a failure to follow proper treatment regimes.
B. Polypharmacy
Patients using four or more drugs at the same time are also in a critical situation and extra care should be taken to prevent harm. Polypharmacy increases the likelihood of side effects, as well as the risk of interactions between medications, and may cause severe harm. If a patient requires many medicines, they must be utilized in an optimal manner, so that the medicines are appropriately prescribed and administered, to ensure that they produce significant benefits with minimal side effects.
C. Transitions of care
Patients are at greater risk during transitions of care. For example: a transfer from the emergency room to the intensive care unit, from a specialty center to a bigger hospital, from a primary care doctor to a specialist, or from one nurse to another during a shift change. Serious mistakes can and do occur at these times.
Source: Adopted from WHO Global Patient Safety Challenge: Medication Without Harm
Next Steps
The Global Patient Safety Challenge on Medication Safety launched in 2017 set a goal of reducing the level of severe, avoidable harm related to medications by 50% over 5 years, globally. It is an inspirational goal. We tried to look for some statistics to see how far we have progressed over the last 5 years but could not find any. We believe gathering reliable data for measurement and comparison is a big challenge.
For healthcare organizations, perhaps you want to focus on capturing medication safety incidents in your hospital and learning from them. To do it effectively, quality and risk management teams can adopt digitized incident reporting systems to capture, investigate and analyze root causes of medication errors, especially in the high priority areas described above.
In the upcoming blogs, we will deep dive to discuss medication safety in high-risk situations, polypharmacy and transitions of care in detail.
Book a demo with us to find out medication error reporting in QUASR with
- ● Digitalized workflow and notifications
- ● Configurable medication error types and forms
- ● Categorizing medication errors
- ● Risk assessment, investigation, RCA and more