David Whitaker, Chair EBA Patient Safety Committee
Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated at 42 billion USD annually.
Errors can occur at different stages of the medication process. Medication errors occur when weak medication systems and/or human factors such as 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.
Multiple interventions to address the frequency and impact of medication errors have already been developed, yet their implementation is varied. A wide mobilization of stakeholders supporting sustained actions is required. In response to this, Medication Without Harm is the WHO third Global Patient Safety Challenge.
Medication errors reported by anaesthesiologists to the National Reporting and Learning System critical incident database in the United Kingdom increased from 100 per month in 2011 to over 530 per month in 20171 and this is usually the second highest category of all the incident types in the Safe Anaesthesia Liaison Group reports.
The third WHO Global Patient Safety Challenge will propose solutions to address many of the obstacles the world faces today to ensure the safety of medication practices. WHO’s goal is to achieve widespread engagement and commitment of WHO Member States and professional bodies around the world in reducing the harm associated with medication.
Medication Without Harm plans to match the global reach and impact of the first two Global Patient Safety Challenges: Clean Care is Safer Care, 2005, and Safe Surgery Saves Lives, 2008. Both of these changed practice for all anaesthesiologists worldwide with, for example, increased emphasis on hand washing and the WHO Checklist. A brochure is available to download from the WHO website,2 Medication Without Harm aims to reduce severe avoidable medication-related harm by 50% globally in the next 5 years, 2017-2022.
It was formally launched at the Second Global Ministerial Patient Safety Summit in Bonn, Germany, on 29 March 2017 and invites Health Ministers to initiate National Plans addressing four domains of medication safety:
- Engaging patients and the public
- Medication as products
- Education, training, and monitoring of health professionals
- Systems and practices of medication management.
This challenge also commits WHO to using its convening and coordinating powers to drive forward a range of global actions on medication safety.
Three priority areas and Anaesthesiology
Medication Without Harm will focus on three priority areas of medication safety that most affect patients, just as hand hygiene and the surgical checklist were chosen as the flagships of the first two challenges. These three areas are
- High-risk situations
- Transitions of care
Each area is associated with a substantial burden of harm, and therefore, if appropriately managed, could reduce the risk of harm to many patients. Anaesthesiology is closely involved with all 3 of these as all anaesthetic drugs are classed as high risk, every anaesthetic is an exercise in polypharmacy, and throughout the perioperative period, from pre-op assessment, premedication, induction, maintenance, recovery, post-op wards/ITU/HDU, and finally home, multiple transitions of medication care take place.
Because of this and the expertise and leadership that Anaesthesiology has demonstrated in the area of medication safety, our professional bodies ESA, EBA, and National Societies should engage with this WHO initiative to make care safer for our patients. We should liaise with our industry and pharmaceutical colleagues who provide our medicines to see where improvements can be made, e.g., labelling, packaging, and prefilled syringes. The patients also have a role and when appropriate could be involved, e.g., in double checking.
As Medication Without Harm says, multiple interventions to address the frequency and impact of medication errors have already been developed, yet their implementation is varied. In the first instance, to start reducing medication harm all involved should make a concerted effort to ensure that existing recommendations are applied wherever possible so that we all get it right first time, every time.
The latest European recommendations for safe medication practice were published in the EJA last year1 by the European Board of Anaesthesiology (EBA) and an initial starting point might be for every anaesthesiology department to review their implementation in their own hospital. To help with this the EBA published a simple 13 point checklist to assess the level of implementation of these recommendations locally.
EBA Safe practice implementation assessment/checklist3
- Are all medications prepared for routine use in anaesthesia, intensive care, emergency medicine, and pain medicine clearly labelled? YES/NO
- Are pre-filled syringes used wherever possible, e.g., atropine, epinephrine, norepinephrine, insulin, morphine? YES/NO
- Is a supply of user-applied colour-coded syringe labels [ISO, 2008. ISO 26825, 2008(E)] available in every necessary location? YES/NO
- Is there a policy for labelling drug-containing syringes and infusion lines? YES/NO
- Is there a policy to minimise the risk of drug contamination and transmission of infections between patients, e.g., the contents of any one ampoule administered to only one patient? YES/NO
- Are drugs stored in ways designed to facilitate their easy identification and minimise the risk of error or misidentification? YES/NO
- Are local anaesthetic agents stored separately from general anaesthetic drugs? YES/NO
- Is intravenous potassium stored securely? YES/NO
- Are bowls, gallipots, or other open containers for drugs, antiseptics, or saline no longer used on the sterile field? YES/NO
- Is there a policy for flushing cannulae to reduce the risk of inadvertent administration of anaesthetic drugs in recovery units or on the ward? YES/NO
- Do all drugs supplied meet current national standards and regulations? YES/NO
- Do all anaesthetists report medication incidents to a local and/or national incident reporting system that is regularly reviewed in departmental meetings so that lessons can be learned and passed on? YES/NO
- Is there a policy for managing and learning from adverse events when they occur? YES/NO
1. The European Board of Anaesthesiology recommendations for safe medication practice: First update. Eur J Anaesthesiol. 2017;34:4–7. http://journals.lww.com/ejanaesthesiology/Fulltext/2017/01000/The_European_Board_of_Anaesthesiology.2.aspx
2. WHO Global Patient Safety Challenge: Medication Without Harm. http://www.who.int/patientsafety/medication-safety/medication-without-harm-brochure/en/
3. Patient Safety Update – January to March 2017. Safe Anaesthesia Liaison Group – October 2017. https://www.rcoa.ac.uk/node/26733