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This webinar is jointly sponsored by the International Society for Quality in Healthcare (ISQua) and American Academy of Pediatrics' Council on Quality Improvement and Patient Safety (AAP COQIPS) Join us for our first ISQua - AAP COQIPS webinar! In this interactive webinar you will learn about implementation tools and resources to decrease medication errors in the ambulatory paediatrics setting. These tools can also be applied to children with medical complexity, who are frequently at higher risk for medication errors due to challenges with care fragmentation, miscommunication, and polypharmacy. Register for the webinar

Pharmacy Forum NI and the DoH Strategic Planning & Performance Group (SPPG) have created a three-part webinar series entitled, ‘A systematic Approach to Insulin Safety in Community Pharmacy’. The first webinar in the series will take place on Wednesday 21 September 2022 at 7-9pm via Zoom and will focus on an introduction to human factors, concepts & tools, and their relevance to patient/medication safety and the wellbeing of the pharmacy team. Event programme and registration Who should attend? These events are targeted at all members of the community pharmacy team who play a part in the safe supply of medicines to patients, namely: pharmacists and foundation trainee pharmacists pharmacy technicians and assistants owners and superintendents medicines safety leads Guest speakers We are delighted to partner with Professor Paul Bowie and Dr Helen Vosper for the three-part event series. Professor Paul Bowie is a Safety Scientist, Medical Educator and Chartered Ergonomist and Human Factors specialist. He has over 25 years’ experience in a range of quality and safety leadership and advisory roles in healthcare, medical defence, military medicine and academia. He gained his doctorate in significant event analysis from the University of Glasgow in 2004 and has published over 150 papers on healthcare quality and safety in international peer-reviewed journals and co-edited a book on safety and improvement. Paul is also Honorary Professor and a PhD supervisor/examiner in the Institute of Health and Wellbeing at the University of Glasgow and a Visiting Professor at Queen’s University, Kingston, Canada. He is Honorary Fellow of the Royal College of Physicians of Edinburgh and the Royal College of General Practitioners, and a Chartered Member of the UK Institute of Ergonomics and Human Factors where he is the patient safety lead of the healthcare specialist interest group Dr Helen Vosper is a chartered ergonomist and graduate of the Loughborough Human Factors Masters Programme and an academic with 15 years’ experience of teaching Human Factors to healthcare students and professionals, including pharmacy students and pharmacists. She is currently the lead for Patient Safety in the School of Medicine, Medical Sciences and Nutrition at the University of Aberdeen. Helen also has a part-time role as a Senior Investigation Science Educator at the Healthcare Safety Investigation Branch and is a scientific adviser in Human Factors and Patient Safety to NHS Education for Scotland.

The Patient Academy for Innovation and Research (PAIR), Organisation of Pharmaceutical Producers of India (OPPI) and DakshamA Health are celebrating World Patient Safety Day, with a webinar on the theme of "Role of stakeholders in GPSAP in the country's context to ensure medication safety". This event will bring all the stakeholders together to discuss their roles in ensuring medication safety and reducing medication-related harm through strengthening systems and practices of medication use, making the process of medication safer and free from harm and galvanizing action on the challenge by calling on all stakeholders to prioritize medication safety and address unsafe practices and system weaknesses. The objectives of World Patient Safety Day 2022 by WHO are - 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. ENGAGE key stakeholders and partners in the efforts to prevent medication errors and reduce medication-related harm. EMPOWER patients and families to be actively involved in the safe use of medication. SCALE UP implementation of the WHO Global Patient Safety Challenge: Medication Without Harm. Register for the webinar The webinar will take place at 3.00-4.30 IST (10.30am-12pm BST)

Medication-related harm accounts for up to half of the overall preventable harm in medical care. Patients in low- and middle-income countries are twice more likely to experience preventable medication harm than patients in high-income countries. Considering this huge burden of harm, “Medication Safety” has been selected as the theme for World Patient Safety Day 2022. To commemorate the day, WHO is organizing a Global Virtual Event, calling on all stakeholders to join efforts globally for “Medication Without Harm”. During the event, stakeholders will discuss medication safety issues within the strategic framework of the WHO Global Patient Safety Challenge: Medication Without Harm, including 1) Patients and the public, 2) Health and care workers, 3) Medicines, and 4) Systems and practices of medication. Interpretations will be available in Arabic, Chinese, English, French, Hindi, Portuguese, Russian and Spanish. Register for the webinar Save the date-flyer_Global Virtual Event WPSD 2022_15 September 2022.pdf

To mark the annual World Patient Safety Day, three organisations - COHSASA of South Africa, AfiHQSA of Ghana and C-CARE (IHK) of Uganda - are collaborating to bring you the latest thinking across Africa regarding 'Medication without harm', the theme for WHO's Third Global Patient Safety Challenge. The Challenge aims to reduce the global burden of iatrogenic medication-related harm by 50% within five years. Join us to hear new ideas, visions and solutions to address medication-related adverse events which cause untold death and suffering around the world. Register for the meeting FINAL INVITE FOR WPSD WEBINAR.pdf

As this year's theme of World Patient Safety Day 2022 is "Medication safety" and increasing awareness about safe medication usage in clinical practice, the Peerless Hospital, Kolkata, India, are organising a one day conference " MediSafeCon" dedicated to increasing awareness about patient safety and medication safety in clinical practice among pharmacists, nurses and doctors. The following sessions by leading doctors, pharmacists, nurses and medicolegal experts of West Bengal and India: 1. Medication safety issues in Critical Care practice 2. Medication safety issues in Pediatric practice 3. Medication safety issues in Oncology practice 4. Medication safety issues in Gastroenterology practice 5. Medication safety issues in Surgical practice 6. Medication safety issues in Domiciliary care 7. Medication safety issues in Telemedicine services 8. Medication errors and Medicolegal implications. Information brochure Medisafecon_brochure.pdf

The International Alliance of Patients’ Organizations (IAPO) and Patient Academy for Innovation and Research (PAIR Academy) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The 4th webinar of the medication without harm webinar series is scheduled on June 18th, 2022, from 11:30 to 12:30 GMT. The theme is "Importance of Systems and Safe Medication Practices for patient safety”. This webinar will emphasize on the "Importance of Systems and Safe Medication Practices for patient safety ", within WHO’s Global Patient Safety Challenge: Medication Without Harm, to improve medication safety. The patient safety series of webinars will focus on the strategic framework of the Global Patient Safety Challenge, which depicts the four domains of the challenge: patients and the public, health care professionals, medicine, and systems and practices of medication, and the three key action areas—namely polypharmacy, high-risk situations, and transitions of care, The series of webinars will share challenges, technical strategies, tools, and patient experiences in implementing the Strategic Framework of the Global Patient Safety Challenge to reduce medication-related harm. Register for the webinar

Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. WHO Patient Safety Flagship has initiated a series of monthly webinars on the topic of “WHO Global Patient Safety Challenge: Medication Without Harm”,. The main objective of the webinar series is support implementation of this WHO Global Patient Safety Challenge: Medication Without Harm at the country level. Considering the huge burden of medication-related harm, Medication Safety has also been selected as the theme for World Patient Safety Day 2022. With each transition of care (as patients move between health providers and settings), patients are vulnerable to changes, including changes in their healthcare team, health status, and medications. Discrepancies and miscommunication are common and lead to serious medication errors, especially during hospital admission and discharge. Countries and organizations need to optimise patient safety as patients navigate the healthcare system by setting long-term leadership commitment, defining goals to improve medication safety at transition points of care, developing a strategic plan with short- and long-term objectives, and establishing structures to ensure goals are achieved. At this webinar, you will be introduced to the WHO technical report on “Medication Safety in Transitions of Care,” including the key strategies for improving medication safety during transitions of care. Register

Patient Academy for Innovation and Research (PAIR Academy) and the International Alliance of Patients’ Organizations (IAPO) are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The theme of the second webinar of the medication without harm webinar series is "Role of Healthcare Professionals in Ensuring Medication Safety”. Register for the webinar

In this blog, Patient Safety Learning marks World Patient Safety Day 2022. It sets out the scale of avoidable harm in health and social care, the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, medication safety. Saturday 17 September 2022 marks the fourth annual World Patient Safety Day. This event was established by World Health Organization (WHO) as a day to call for global solidarity and concerted action to improve patient safety. It aims to bring together patients, families, carers, healthcare professionals and policymakers to show their commitment to patient safety. Avoidable harm in health and social care What is patient safety? Simply put, patient safety is concerned with avoiding unintended harm to people during their care and treatment. WHO describes it as follows: “Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur.”[1] Modern health and social care is incredibly complex and complicated, meaning that there are range of different ways in which unintended avoidable harm can occur. Each year, millions of patients suffer injuries or die because of this, with WHO stating that unsafe care is likely one of the top ten leading causes of death and disability worldwide.[2] In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed.[3] This comes at a huge financial cost, with the Organisation for Economic Co-operation and Development (OECD) estimating that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending.[4] Avoidable harm also has an untold physical and emotional impact on those affected, resulting in a loss of trust in the healthcare systems by patients, and frustration and a loss of morale among healthcare professionals at not being able to provide the best possible care. Need for transformation in our approach to patient safety The impact of avoidable harm and the need to make significant improvements to patient safety is well-established in health and social care. However, despite this knowledge, and the hard work of many people involved in the sector, avoidable harm continues to persist at an unacceptable rate. At Patient Safety Learning we believe that the persistence of avoidable harm is the result of our failure to address the complex systemic causes that underpin it. We argue that there needs to be a transformation in our approach to this problem. Key to this is ensuring patient safety is treated as core to the purpose of health and social care, not simply as one of several competing strategic priorities to be traded off against each other. In our report, A Blueprint for Action, underpinned by systemic analysis and evidence, we identify six foundations of safe care for patients and these practical actions to address them:[5] Shared Learning – organisations should set and deliver goals for learning, report on progress and share their insights widely for action. It is not enough to say, ‘we’ve learned from incidents of unsafe care’, we need to see action for improvement and impact. Leadership – we emphasise the importance of overarching leadership and governance for patient safety. This is not just about governance; it is about behaviours and commitment too. Professionalising patient safety – organisations need to set and deliver high standards for patient safety. These need to be used by regulators to inform their assessment of whether organisations are doing enough to prevent avoidable harm and assess whether they are safe. Patient Engagement – to ensure patients are valued and engaged in patient safety, at the point of care, if things go wrong and for redesigning health care for safety. Data and Insight – better measurement and reporting of patient safety performance, both quantitative as well as qualitative. Just Culture – all organisations should publish goals and deliver programmes to eliminate blame and fear, introduce or deepen a Just Culture, and measure and report progress. Medication safety When considering avoidable harm in health and social care, unsafe medication practices and medication-related harm are one of the leading causes of this, with WHO noting that: Medication harm accounts for 50% of the overall preventable harm in medical care.[6] $42 billion (US dollars) of global total health expenditure worldwide can be avoided if medication errors are prevented.[6] This year’s World Patient Safety Day focuses on the issue of medication safety and the need to build on the existing WHO Global Patient Safety Challenge: Medication Without Harm. The campaign emphasises the need to adopt a systems approach to this challenge, promote medication safety practices to prevent medication errors and reduce medication-related harm.[7] The Global Challenge was launched in 2017 with a goal “to gain worldwide commitment and action to reduce severe, avoidable medication-related harm by 50% in the next five years”.[8] As we reach the end of this period, Patient Safety Learning believes that it is important now that countries report publicly on their progress against this, enabling WHO evaluate both positive developments and where improvement is required. Medication safety covers a huge range of different issues and concerns and here we will highlight a few examples from Patient Safety Learning’s work and topical issues highlighted on our award-winning patient safety platform, the hub. Listening and responding to patient concerns A key barrier to improving patient safety around medication concerns the dismissal of concerns raised by patients when harmful side effects occur. A recent example of this in the UK was highlighted by the Independent Medicines and Medical Devices Safety (IMMDS) Review, which investigated a truly shocking degree of avoidable harm to patients over a period of decades relating to two medications, hormone pregnancy tests and sodium valproate, and pelvic mesh implants. The Review exposed a range of medication safety concerns, including a lack of informed consent, failures by incident reporting schemes to recognise safety concerns and a failure to support patients after unsafe care, stating: “As we have seen and heard, all too often patient reports of harm are either not listened to or are dismissed as subjective, unscientific and anecdotal.”[9] Key to highlighting these issues, and pushing for change, was the tenacious work of campaigning patients and families affected by this, as described in a recent interview on the hub with Marie Lyon, Chair of the Association for Children Damaged by Hormone Pregnancy Tests. In response to this Review there will soon be new Patient Safety Commissioner roles created in England and Scotland. While these roles can provide a new voice and hopefully influence for patients in relation to medication safety in the UK, this must also be accompanied by a shift in attitudes and approach towards patients’ involvement in care and their safety. Packaging and processes The WHO Medication Without Harm initiative recognises that one of the key challenges to the safe administration of medication often lies in complex and unclear processes which can result in mistakes that lead to patient harm. An example of this is when packaging and labelling of medications creates error traps, situations that could lead into avoidable harm in a busy, pressurised health and social care workplace, such as different medications being stored together in almost identical packaging. We have been collating different examples from healthcare professionals of look-alike medicines on our error traps gallery on the hub. We also need to look at how we can reduce the complexity around medication prescription and administration to reduce the risk of mistakes that lead to harm. Laurence Goldberg highlights examples of this such as regards to ready-to-administer injections and unit dose drug distribution in a new blog featured on the hub. Engaging with patients in the medication process Building on our previous comments around listening to patient concerns, actively involving them in their care is also a key issue in ensuring medication safety. In our recent analysis of investigation reports by the Healthcare Safety Investigation Branch (HSIB) in England we have seen numerous examples where family members of patients have played a key role in spotting and alerting healthcare professionals to safety concerns. Cases of this vary from appropriate insulin administration to safety concerns around the prescription of liquid morphine. WHO have developed a helpful tool to support patient involvement in this area, 5 Moments for Medication Safety. This helps to highlight how the risk of harm can be reduced by involving patients at different stages of the medication process. The implementation gap As with many other issues in patient safety, a key challenge in reducing medication-related harm remains overcoming the ’implementation gap‘, the difference between what we know improves patient safety and what is done in practice. In our report from earlier this year, Mind the implementation gap, we highlighted how too often we fail to translate patient safety insights and learning into practical improvements, due to a lack of systems for sharing learning, absence of oversight and unclear patient safety leadership. Returning to the IMMDS Review we can see a clear example of the implementation gap in relation to sodium valproate. Despite a clear body of evidence about the risks, birth defects or development delays associated with taking this medication during pregnancy, the safety actions identified by the review and ongoing campaigning by groups such as the Independent Fetal Anti-Convulsant Trust, pregnant women and birthing people in the UK continue to be prescribed this medication. In addition, they do not always receive the appropriate advice on the risks associated with this. There is much that still needs to be done in medication safety to improve our approach to not only sharing good practice but ensuring that this is implemented widely and consistently. Share your experience with us Do you have an experience to share around medication safety as a patient, carer or family member? Or perhaps you are a healthcare professional looking to share your frontline insights to help improve safety? Join the conversation by signing up to our patient safety platform the hub and sharing your views, or get in touch with us by emailing [email protected]. Related reading You can find a wide range of medication safety related articles on issues such as medication administration, labelling, patient medication stories and medicine management on the medication section of our patient safety platform the hub. We’ve also published several articles on this subject specifically for World Patient Safety Day this year which you can find below: Patient Safety Spotlight interview with Angela Carrington, Lead Pharmacist for Medication Safety in Northern Ireland Reducing medication errors: a blog from Laurence Goldberg for World Patient Safety Day Top picks for World Patient Safety Day 2022: Medication safety in hospitals Top picks for World Patient Safety Day 2022: Patient engagement for medication safety Top picks for World Patient Safety Day 2022: Medication safety in social care References WHO, Patient safety – About us, Last Accessed 13 September 2022. WHO, 10 facts on patient safety, 26 August 2019. NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. OECD, Patient Safety, Last Accessed 20 October 2021. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. WHO, World Patient Safety Day 2022, Last Accessed 14 September 2022. WHO, Medication Without Harm, Last Accessed 14 September 2022. WHO, Medication Without Harm: WHO Global Patient Safety Challenge, 2017. The IMMDS Review, First Do No Harm, 9 July 2020

In 2022, the World Health Organisation’s annual World Patient Safety Day focused on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list seven top Learn articles about medication safety in social care. 1 Natural Care Forum: Medication safety in care homes Medication safety in care homes is an ambitious cross-sector partnership project aiming to improve the medicines pathway for residents in care homes. 2 Blog - Managing medicines in care homes – four top tips In this blog, Steve Turner, a qualified nurse specialising in clinical educational and patient engagement, offers up four tips for managing medicines in care home settings, under the following headings: Care Homes must have a medicines policy that is regularly reviewed People must have an accurate listing of their medicines on the day they transfer to the care home People who live in care homes should have at least one multidisciplinary medication review per year Ensure you have safe systems for administering and recording medicines 3 NICE/SCIE - Giving medicines covertly: A quick guide for care home managers and home care managers providing medicines support (2019) People should not be given medicines without their knowledge if they have the mental capacity to make decisions about their treatment and care. This guide from the National Institute for Healthcare Excellence (NICE) and Social Care Institute for Excellence (SCIE) is aimed at care home managers and anyone providing medicines support in care homes. It includes information on capacity and consent, what the process is if there is a decision to give medicines covertly and what to do if you need to make a medication decision urgently. 4 Reporting medicine-related incidents in social care - Care Quality Commission This document from the Care Quality Commission (CQC), sets out when medication errors need to be reported to the CQC within social care. 5 Medication safety in nursing home patients (5 July 2022) Medication safety is a major issue in long-term social care due to the number of medications taken by many older people. This editorial in BMJ Quality & Safety looks at why managing medications in care homes is so complex and highlights potential interventions to improve medication safety in long-term care settings. 6 The AHSN Network: Medicine safety in care homes national report (20 March 2020) Medication errors are a common issue within the care home sector, impacting on the health and wellbeing of residents as well as creating challenges for care home staff and managers. This report addresses the issue of medication safety in care homes in England. Through intense engagement with a representative sample of care homes and stakeholders involving an electronic survey, workshops and conversations, Patient Safety Collaboratives have sought to understand the reasons for medication errors and how these could be avoided in the future. 7 Blog - Inappropriate prescribing during a pandemic: dementia and antipsychotics A growing number of people with dementia who live in care homes are being prescribed antipsychotic medication, but there are serious questions about whether these drugs are being prescribed appropriately. In this blog, a family describes how their father with Alzheimer’s disease came to be prescribed antipsychotic medication at his care home. They raise concerns about the decision to prescribe antipsychotics when there were obvious non-drug based alternatives to pursue, the lack of involvement the family had in the decision-making process and the negative ways in which the medication has affected their father’s personality. Take a look at our other medication top picks articles: Medication safety in hospitals and Patient engagement for medication safety.

The World Health Organization’s annual World Patient Safety Day in 2022 focused on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety. Here we list ten tools and articles related to patient engagement and medication safety, including an interview with a patient advocate campaigning for transparency in medicines regulation, a blog outlining family concerns around prescribing and consent, and a number of projects that aim to enhance patient involvement in using medications safely. 1 The question that will save lives: Interview with Katinka Blackford Newman, founder of Antidepressant Risks Antidepressant medications are taken by millions of people globally. A small percentage of people who take them will experience rare but dangerous adverse reactions. In this interview, Katinka Blackford Newman tells us about her personal experience of antidepressant-induced psychosis and how this led her to campaign for increased awareness about side effects. She highlights a widespread lack of education and awareness about the risks associated with antidepressants and outlines why she is asking suicide prevention charities to ask callers one simple question about their medication. 2 Belfast Healthy Cities: Pharmacy Schools Programme (2021) The Pharmacy Schools Programme is an innovative teaching resource developed by Belfast Healthy Cities. Using a health literacy approach, it is designed to be used in primary schools in Northern Ireland to help educate children about self-care, medication safety and community pharmacy services. 3 WHO - Medication safety webinar series: engaging patients and families for medication safety (8 March 2022) As part of its Third Global Patient Safety Challenge: Medication Without Harm, WHO launched a series of webinars to introduce the strategic framework, technical strategies, tools for reducing medication-related harm. You can access the presentations from this webinar focused on engaging patients and their families to improve medication safety: Patient engagement tool: “5 Moments for Medication Safety”, Nagwa Metwally and Helen Haskell Patients, families and health workers partnering for medication safety, Dr Irina Papieva Developing programmes for patient and family engagement - Canadian experience, Ioana Popescu and Maryann Murray 4 Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests In this interview, Marie Lyon talks about her campaign for justice for families affected by hormone pregnancy tests, why she is passionate about reforming medicines regulation and the important role patient campaigners play in improving patient safety. 5 Blog - Please don’t undermine my pain relief! A call for learning and respect for patients with long term needs This blog calls for action on the careful review of established pain medication when a patient is admitted to hospital. The author, Richard von Abendorff, describes the experience of two elderly patients who suffered pain due to their long term medication being stopped when they were admitted to hospital. He highlights the importance of ensuring that pain management needs are not ignored or undermined and argues that there needs to be carer and patient involvement and their consent when making a decision to stop established pain medication. 6 HSE Ireland - My Medicines List leaflet (January 2020) This leaflet produced by the Irish Health Services Executive (HSE) provides a central place for patients to record information about their medications. It acts as a reference point for patients to use when discussing their medications with a healthcare professional and includes a reminder of the Know, Check, Ask campaign, aimed at reducing medication errors in the community. 7 Blog - Digitising pharmacy: Bilingual medication information on pharmacy dispensing labels (July 2022) This blog by NHS England looks at how a service which provides bilingual medication information is helping to reduce healthcare inequalities and medication errors in London. Written Medicine’s software allows pharmacies and hospitals to translate and print medication information, instructions and warnings. Drawn from a dataset of 3,500 phrases, printed labels are available in fifteen different languages. The bilingual labels help patients take ownership of their treatment, giving them a better understanding of how to take their prescribed medication. The solution is helping to reduce errors, improve medication adherence and enhance patient safety and experience. 8 Medication supply issues: Mast cell activation syndrome (MCAS) Joy Mason is the Director of Operations, Services and Engagement at Mast Cell Action. In this blog, Joy tells us more about Mast Cell Activation Syndrome and how medication supply issues are impacting people’s lives and causing avoidable harm. 9 Blog - Inappropriate prescribing during a pandemic: dementia and antipsychotics A growing number of people with dementia who live in care homes are being prescribed antipsychotic medication, but there are serious questions about whether these drugs are being prescribed appropriately. In this blog, a family describes how their father with Alzheimer’s disease came to be prescribed antipsychotic medication at his care home. They raise concerns about the decision to prescribe antipsychotics when there were obvious non-drug based alternatives to pursue, the lack of involvement the family had in the decision-making process and the negative ways in which the medication has affected their father’s personality. 10 Digital-only prescription requests: An elderly woman sent round the houses In this blog, a doctor tells us how their elderly mother was met with multiple digital barriers when trying to access her medications. Describing the situation as a frustrating goose-chase, He summarises the blog by questioning what measures are put in place to safeguard patients during digital transformations. Take a look at our Top picks: Medication safety in hospitals

This year's World Patient Safety Day, due to take place on Saturday 17 September 2022, will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. In this blog for the hub, Laurence Goldberg, an independent pharmaceutical consultant, looks at how we can reduce drug administration errors by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient. A medication error is defined 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,” according to the National Coordinating Council for Medication Error Reporting and Prevention. An estimated 237 million medication errors occur in the NHS in England every year.[1] This number represents the sum of medication errors over all stages of the medication use process. Most errors occur during drug administration (54%), followed by prescribing (21%) and dispensing (16%). The majority of medication errors (72%) have little/no potential for harm, and only 2% have potential to cause severe harm. One of the recommendations to reduce medication errors and harm is to use the “five rights”: the right patient, the right drug, the right dose, the right route, and the right time. According to the NHS Patient Safety Strategy, “Medication errors are any Patient Safety Incidents (PSI) where there has been an error in the process of prescribing, preparing, dispensing, administering and monitoring or providing advice on medicines". The NHS Medicines Safety Improvement Programme has been established to address the most important causes of severe harm associated with medicines and aims to reduce severe avoidable medication-related harm by 50% by March 2024. Prescribing errors can be reduced by incorporating decision support software into the electronic prescribing protocol, although many of the warnings generated by this type of software are of no clinical significance and are often regarded as an intrusion or an inconvenience and are usually ignored. A pharmacist’s signing off a prescription before it is dispensed will also capture potential prescribing errors. Dispensing errors are usually identified before the prescription is issued by a second check but with the introduction of dispensing/distribution robots in most hospital pharmacies, dispensing errors have almost been eliminated. The focus today is to reduce drug administration errors. In surveys, the most common errors were late or early administration of drugs or drug omission. Distractions and interruptions are a regular part of nurses’ working lives. If these occur when nurses are preparing and administering medicines, they can lead to drug errors that compromise patient safety. Poor numeracy and the need for complex calculations have also been highlighted as contributory factors to medication errors in both hospitals and in the community. However, many of these errors can be eliminated by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient. Individual doses should have machine readable codes on the label to ensure correct drug identification. Ready-to-administer injections (RTA) Injectable drugs should be made available in a ready-to-administer (RTA) format. The World Health Organization (WHO) defines RTA as “an injectable medicine that requires no further dilution or reconstitution and is presented in the final container or device, ready for administration or connection to a needle or administration set”. The preparation of IV medications at the bedside requires multiple steps and reducing these complex steps and manipulations can reduce the number of errors. Additionally, the use of prefilled RTA syringes can help reduce unnecessary wastage of medications by optimising pharmaceutical product size. Healthcare professionals responsible for administering injectable drugs should demand RTA preparations. In the first instance, hospital pharmacies should prepare high-risk injectable medicines in their aseptic compounding units or purchase them from third party contractors. Looking to the future, the pharmaceutical industry should offer licensed injectable medicines in a RTA format. Manufacturer-prepared RTA prefilled syringes can play an important role in simplifying these processes and reducing errors and potential patient harm. When contracts for injectable drugs are awarded, priority should be given to those products that are presented in a RTA format. Purchasing for safety must be implemented and not just discussed. Unit dose drug distribution (UDD) Unit dose drug distribution is a system that provides the prescribed dose of a specific drug for a certain patient at a specific time. It differs from other systems in that each dose of a prescribed drug is packaged individually, in a ready-to-administer form. Each dose is labelled so that it retains its identity right up to the time it is administered to the patient. The package, labelled with the drug name, strength, batch number, and expiry date, virtually eliminates contamination resulting from transfer and handling of the drug. Unused medications can safely be reissued. In addition, the system sharply reduces the potential for medication errors. For blister-packed tablets and capsules, separation of individual blisters and over-wrapping them in individual sachets has the advantage that the integrity and stability of the original pack is not compromised. Using a ‘closed-loop’ process where the patient, the drug and the healthcare worker are identified, a safer system for drug administration can be established using unit doses with the added advantages of reduced drug wastage, reduction in nursing time and reduced inventory on the ward. Medication errors, particularly drug administration errors can be reduced considerably by redesigning packaging, eliminating the preparation of doses in clinical areas and simplifying the medicine rounds. This can all be brought about at no overall additional cost to the healthcare provider by utilising the efficiencies generated by the new practices. Reference 1. Elliott RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf 2020:1-10. doi:10.1136/ bmjqs-2019-010206.

The World Health Organization’s annual World Patient Safety Day on 17 September 2022 focused on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list 8 helpful reads related to medication safety in hospital settings. 1 Error trap gallery - medication the hub’s error trap gallery provides a place to share examples of error traps you come across in your day to day work, including error traps relating to medications. An error trap is a situation that could lead to avoidable harm if not mitigated. It is a situation where the circumstances work alongside human limitations to make errors more likely—for example, packaging design that makes it hard to distinguish one medication from another. Medications with similar packaging are one of the most common error traps in busy hospitals, and being aware of them can help reduce the risk of mistaking one medicine for another. 2 Healthcare Safety Investigation Branch investigation report: Unintentional overdose of paracetamol in adults with low bodyweight (24 February 2022) The Healthcare Safety Investigation Branch (HSIB) carries out investigations into incidents of harm to gather and share learning that may help prevent similar errors happening again. In this investigation report, they look at the case of an 83-year-old woman who developed paracetamol-induced liver toxicity as a result of being overprescribed paracetamol while in hospital. The report presents key findings and safety observations around prescribing paracetamol to underweight adults. HSIB reports on a wide range of medication errors, and you can access all of their reports on the hub. 3 Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT Antibiotic underdosing is a widespread issue in the healthcare system. The use of modern infusion pumps to deliver intravenous (IV) medications has resulted in the practice of flushing IV lines being lost in some specialties. Failure to give full doses of IV antibiotics poses significant risks to individual patients as well as adding to the problem of antimicrobial resistance (AMR). In this interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT. 4 Blog - Unit-dose medicines distribution for hospital inpatients In this blog, independent pharmaceutical consultant Laurence Goldberg discusses the effectiveness and the potential for harm of unit-dose medicines distribution, often used in hospital settings as a way to save clinical staff time. In unit-dose dispensing, medication is dispensed in single doses in packages that are ready to administer to the patient. It can be used for medicines administered by any route, but oral, parenteral, and respiratory routes are especially common. Laurence highlights that although more research is needed, published studies have reported reductions in medication errors with unit-dose dispensing when compared with alternative dispensing systems such as ward stock systems. 5 Blog - Action needed make insulin administration in hospitals safer This blog by Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents. 6 PSNet - Medication safety events related to diagnostic imaging (8 July 2022) This case report by Patient Safety Network in the US looks at the benefits and risks of using sedative medication in patients undergoing diagnostic imaging such as an MRI scan. It looks at two separate cases where sedation was used so that the patient could tolerate having a scan, one of which resulted in the patient being intubated for several days due to severe acute respiratory distress syndrome as a result of aspiration while in the MRI machine. 7 Parkinson's UK: Time critical medication resources for health professionals Patients with Parkinson’s are at risk of significant harm if they don’t get their medication on time, every time. ‘On time’ means within 30 minutes of the patient’s prescribed time. Even short delays can worsen symptoms such as rigidity, pain and tremors, increasing the risk of falls. Over half of people with Parkinson’s don’t get their medications on time, every time in hospital. This leads to worse patient outcomes, longer recovery times and increased costs to the NHS. Parkinson’s UK is working collaboratively to improve the delivery of time critical Parkinson's medications and have a number of resources to support healthcare professionals. 8 National campaign aims to reduce patient harm from infiltration and extravasation Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and extravasation and reduce avoidable harm. In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety. Take a look at our Top picks: Patient engagement for medication safety

Sarah Kay and Jaydee Swarbrick are involved in the Patient Safety in Primary Care Project in Dorset. In this blog, they summarise a recent event they held to share learning from medicines incidents. Each NHS Trust and local pharmacies in Dorset have been promoting awareness and providing updates for staff and patients on medications without harm and medicines safety following World Patient Safety Day in September. On Monday 17 October we held a face-to-face event to share learning from medicines incidents and to specifically focus on the safety improvement programme to reduce harm from opiate drugs in our communities. This provided an excellent opportunity to network with other healthcare professionals. Speakers on the day were: Head of Medicines Improvement at NHS Dorset who set the scene for the morning with facts and figures for discussion. Clinical Lead for the Wessex Academic Health Science Network Polypharmacy programme provided an update on the wider safety improvement work. Patient Safety Specialist with NHS Dorset presented a patient story of a person that died following accidental fatal intoxication with liquid morphine. Deputy Chief Pharmacist at Dorset County Hospital (DCH) and long serving Medicines Safety officer in Dorset shared the improvement work that has taken place in DCH in relation to opiate prescribing on discharge. Dr Sarah Kay, GP lead for Patient Safety with NHS Dorset, concluded the morning with a facilitated discussion session to share best practice and consider how organisations can work together to improve medicines safety. Attendees included Primary Care Network (PCN) pharmacists, hospital trust pharmacists, NHSD patient safety teams, medicines optimisation team, primary care team, AHSNs. In Dorset we prescribe almost double the volume of liquid opioids to patients in our hospitals when compared with others in our region. This increases the risk of prolonged prescribing in primary care, which can lead to long-term tolerance and dependency, and contributes to nearly 700 patients requesting multiple liquid opioid prescriptions each month for chronic non-cancer pain. This prescribing is having a disproportionate impact on women between 40 and 60 years of age and in more deprived areas of our county. At the event, we heard from some acute trusts and PCN colleagues who are having success in reducing opiate usage and promoting safe pain management strategies for people, as well as from the Wessex AHSN who can support ongoing improvement programmes. The morning was compered by NHS Dorset Patient Safety Partner (volunteer lay role) Simon Wraw who ensured the patient perspective was part of our discussions. The opportunity to meet face to face with colleagues was really valuable, as well as making new counterpart connections for each professional group. Feedback from attendees was positive and we hope to run a similar event in the future with a different topic focus. On the topic of networking, we have also contributed to the setup of the NHSE South West GP Quality Network. A scoping meeting was held in October to co-produce a plan for the network with participants. We hope to build the network, so if you work in any patient safety role across the South West and have an interest in general practice and connecting with colleagues to share good ideas and troubleshoot problems together please get in touch. The next network meeting will be 22 February 2023. Please email [email protected] for an invite. Further reading See our recent Patient Safety Spotlight interview with Sarah and Jaydee.