Medication safety is an integral component of patient safety and has been re-emphasised in recent reports and initiatives. In March 2017, the World Health Organisation (WHO) announced the third global patient safety challenge, Medication Without Harm, with the aim of reducing severe avoidable harm related to medications by 50 percent over five years, globally. The focus of the challenge is medication errors at different stages of medicines use due to weak medication systems and/or human factors, across four domains:
- Patients and public
- Healthcare professionals
- Systems and practices
Three areas identified for early priority actions are high-risk patients and situations, polypharmacy, and transitions of care. The WHO implementation response includes strengthening human resource capacity through leadership development and skill building, promoting and supporting research in the area, and engaging with regulatory agencies and other international agencies to improve packaging and labelling. Of note, the skill building initiative involves an update of the medication safety curriculumwithin the WHO patient safety curriculum guide.
The English response to the WHO challenge has been two-fold. Firstly, through commissioning a rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK, which was published in February 2018 and received extensive media and ministerial attention.
The key finding of the rapid evidence synthesis was the great variation in error rates (ranging from 0.2 percent to over 90 percent in primary care, care homes and secondary care at the various stages of the medication pathway), as well as cost estimates (from €67.93 per intercepted error for inhaler medication, to nearly €7 million for litigation claims associated with anaesthetic error). However, the authors recognised the limitations of the findings due to little evidence of how medication errors lead to harm, and the potential underestimation due to studies being over 10 years old, and a focus on short-term costs and patient outcomes.
the call to develop a repository of good practice indicates that some of the work may already be taking place, but in isolation or silos
The report highlights that non-steroidal anti-inflammatory drugs, anticoagulants and antiplatelets cause over a third of admissions due to avoidable adverse drug reactions, and that older people are more likely to suffer avoidable adverse drug reactions.
Secondly, a short-life working groupwas established to provide advice to the Secretary of State for Health and Social Care on the scope of a programme of work designed to improve medication safety. The recommendations highlight the role of better linkage and use of electronic patient records in improving medication information availability and access for patients as well as healthcare professionals, and the accelerated rollout and optimisation of hospital electronic prescribing and medicines administration systems.
Other early priorities include:
- focus on patient-friendly and clear packaging and labelling
- rollout of proven interventions in primary care such as the PINCERquality improvement tool
- the development of a prioritised and comprehensive suite of metrics on medication error aimed at improvement, and
- the development of a repository of good practice.
Pharmacists and medication safety officers (the majority of whom are pharmacists) are ideally placed to lead, engage with and contribute to this agenda. For example, at a recent seminar hosted by the UCLH-UCL Centre for Medicines Optimisation Research & Education, two potential areas for improvement using an improvement science approach were agreed: encouraging self-administration during hospitalisation, and improving communication and documentation about medicines across transitions of care.
In fact, the call to develop a repository of good practice indicates that some of the work may already be taking place, but in isolation or silos. The repository is likely to be hosted on the NHS Specialist Pharmacy Service (SPS).
What can you do?
- Identify who your Medication Safety Officer is, and find out what is happening in your local area
- Share your good practices through the UKCPA Medicines Safety & Quality Group, or national MSO and SPS medicines use and safety networks
- Begin to practice: KNOW, CHECK, ASKbefore you give it and spread the word!