The Burden of Medication Error

A global challenge marks the advent of the World Health Organization (WHO) 4^th World Patient Safety Day on 17^th September 2022 – ‘reducing risks and errors associated with medication use’.

With medication errors being the leading cause of avoidable harm in healthcare globally, the theme for this year’s World Patient Safety Day – ‘Medication Safety’, with the slogan ‘Medication without Harm’ is taking centre stage.

When the WHO announced that World Patient Safety Day 2022 would focus on the risks and errors associated with medication use, it was a welcomed theme. By understanding the Strategic Framework of the Global Patient Safety Challenge, and associated objectives, nurses across the globe can become actively involved in improving patient safety and rise up to the significant challenge ahead.

This challenge, which reaffirms the objectives of the WHO Global Patient Safety Challenge: Medication Without Harm launched in 2017, calls on global healthcare leaders to take action against the iatrogenic impact of medication errors, by recognising those practices that are high risk including polypharmacy; ‘look-alike and sound-alike medication’, poor staffing levels and inappropriate skill mix; all acknowledged causes of medication errors.

Causes of Medication Errors

The causes of medication errors, as with many other patient safety incidents are complex and can include:

• System failings
• A lack of effective education and training
• Poor working environments
• Ineffective policies and procedures
• The effect of poor staffing levels
• Lack of appropriate skill mix
• Ineffective communication
• Simple human error

I am sure you can add your own to this list.

So, how can we all contribute to the ‘Call to Action’?

The WHO ‘Call to Action’ requires us to: Know. Check. Ask.

What does this mean to you? For me it means:

Knowing

• Organisational policies and procedures in relation to medicines management
• Everything we need to know about the medication we are prescribing
• Everything we need to know about the medication we are administering
• The 5 Moments of Medication Safety

Checking

• Am I knowledgeable enough?
• Am I experienced enough?
• Am I confident enough?
• Am I well enough?
• Do I need help?

Acting

• Raising awareness and becoming actively involved in the WHO campaign
• Supporting each other – we should never be too busy to help a colleague – ever!
• Working in a responsible manner and demonstrating accountability for our actions
• Becoming involved in auditing medication errors and acting to reduce risk
• Challenging potentially inappropriate prescribing – increasing your knowledge will help you build the confidence to do this
• Recognising that we all have the capacity to ‘get it wrong’; for ostensibly ‘humans make mistakes’
• Reporting an error
• Reporting a near miss

Nurses – Be kind and compassionate when your colleagues make an error. Understand the Human Factors associated with medication and patient safety errors and seek to understand what happened. Most healthcare professionals do not go to work that day with the intention of making an error. Although there are some whose intentions are dubious; these individuals are far and few between.

Work collaboratively to create a Patient Safety Culture

Developing a safety culture in which all staff, irrespective of roles and responsibilities, feel empowered to raise concerns is an essential element of any healthcare organisation seeking to reduce patient harm, and not simply within the NHS.

The key to reducing errors is creating a fair and just patient safety culture. Nurses should not be made scapegoats for the delivery of increasingly pressurised care at a time of unparalleled nursing shortages, a crisis which is unmatched in modern times; instead we should be supported.

We as nurses have our own role to play in creating a patient safety culture and reducing errors. Disappointingly however, staff working within healthcare settings continue to be overwhelmed by the challenge of speaking up, that they fail to act. So, despite the introduction of Freedom to Speak up Guardians created as a response to the Francis report; and the importance of the Duty of Candour, a lack of confidence in speaking up remains evident.

Get involved

Patient Safety is everyone’s responsibility. Don’t delegate it to someone else. Engage with World Patient Safety Day 2022 and aim to drive forward effective change. Use campaign materials to shine a light on the importance of keeping patients safe. Seek to create a workplace culture whereby everyone wants to come to work; simply because it’s a great place to work.

Speak up for Patient Safety

World Patient Safety Day was introduced in 2019. This is a reminder of the focus of previous campaigns.

World Patient Safety Day 2021 – urged all stakeholders to “Act now for safe and respectful childbirth!” with the theme: “Safe maternal and newborn care”.

World Patient Safety Day 2020 – asserted the importance of keeping healthcare workers safe with the theme: “Health worker safety: a priority for patient safety” and the launch of the Charter that seeks to ensure health worker safety across the globe.

World Patient Safety Day 2019 – called upon all healthcare workers to – Speak up for patient safety with the theme: “Patient safety: a global health priority”.

My blog published by the QNI in 2021 focused on the importance of Human Factors and the significance of responding in a fair and just way when errors occur.

Access Learning Opportunities – Stay ahead of the challenges we face

Access learning opportunities that improve your understanding of patient safety and as nurses can help support Revalidation.

Access and complete the NHS Patient Safety Syllabus on eLearning for Healthcare.

Act to understand the WHO Global Patient Safety Action Plan 2021 – 2030.

Remind yourself of the Compassion in Practice Strategy and the 6Cs and use the NMC Code to guide your actions and challenge poor practice and behaviours.

Catherine Best QN

Twitter: @CBest_23