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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

To mark World Patient Safety Day (WPSD) 2022 and in support of WHO's 5 moments for medication safety, the International Alliance of Patients' Organization (IAPO) has launched the "Humour me into medication safety" cartoons highlighting the 5 moments for medication safety - a patient engagement tool focusing on the key moments where action by the patient or caregiver can reduce the risk of harm associated with the use of medications. It aims to engage and empower patients to be involved in their own care through collaboration with health professionals. Here are a couple of the cartoons. Download all of the cartoons here.

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.