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15.08.18

Medication without harm

Source: NHE July/August 2018

The World Health Organization’s (WHO’s) Third Global Patient Safety Challenge, ‘Medication without harm,’ is ambitious, but it must not detract from the ongoing work of healthcare professionals, writes consultant pharmacist Gillian Cavell.

On 29 March 2017, the WHO launched its Third Global Patient Safety Challenge, ‘Medication without harm.’ The goal of the challenge is to reduce the level of severe, avoidable harm related to medications by 50% over five years, globally. 

It has been stated that, worldwide, medication errors cost an estimated $42bn annually. Medication error as a source of avoidable patient harm and death needs to be formally addressed, and this Global Patient Safety Challenge is setting out a broad framework within which to reduce harm from medicines. Three priority areas for action have been identified: high-risk situations, polypharmacy, and transitions of care.

The high-risk situations referred to in the WHO Patient Safety Challenge include the use of certain classes of medicines which are more likely to be associated with adverse drug events – either because small errors can be associated with serious harm, or because of the vulnerability of the types of patients who are likely to be prescribed these medicines. 

These drug classes – which include high-strength electrolytes, anticoagulants, insulin, opiates, sedatives and chemotherapeutic agents – have been the subject of patient safety alerts issued by the National Patient Safety Agency and NHS Improvement (NHSI) in the past. The safe use of these medicines remains high on the medication safety agenda across the NHS, where systems and practices have been put in place to minimise the risk of errors. 

More recently, increased emphasis has been placed on the importance of deprescribing medicines known to be associated with harm in particular patient groups – especially where multiple medicines are prescribed (polypharmacy) – and ensuring effective communication of changes to medicines when patients are transferred between healthcare settings.

The goal that has been set certainly is a challenge. In order to demonstrate a reduction in medication-related harms, we need to be able to measure the current rate of ‘harm.’ This is not going to be easy. We know that medicines and medication errors can cause ‘harm,’ but not all ‘harm’ is caused by medicines – and not all medicines use causes ‘harm.’ If it does occur with medicines use, that harm might not be preventable, as is the case with adverse drug reactions. The challenge specifically refers to severe harm, but the degree of harm is not specifically defined. 

Where adverse incidents do occur, there is an expectation for those incidents to be reported either through the National Reporting and Learning System or, in the case of adverse drug reactions, to the Medicines and Healthcare Regulatory Agency via the Yellow Card Scheme. 

However, as our reporting systems are voluntary, the data cannot be assumed to be complete. Qualitatively, the data is important and relevant, but when it comes to actual numbers of incidents resulting in harm, quantitative analysis is not reliable.

The increasing use of information technology – especially electronic patient records, electronic prescribing and electronic prescribing & medicines administration (EPMA) – enables the capture of data on the quality of prescribing and medicines use. Such systems have been used widely to support the development of safer ways of using medicines. Indicators of safe prescribing in hospitals which could be used to develop clinical decision support within EPMA systems have been described. The use of antidotes to reverse potential drug-related harms can be measured and has been used previously as part of the Medication Safety Thermometer to measure medication-related harm. 

We need to ensure that the technology that is increasingly being used to optimise medicines is designed to provide the information we need to measure its impact on the care we give to patients in the NHS. 

The challenge is to refine and combine existing intelligence around the safe use of medicines and potential harms associated with medication errors and link these to actual patient outcomes within the electronic databases currently being used or developed for use within the NHS. Where technological interventions have been shown to improve the way medicines are used, learning should be shared with NHS England for wider implementation.

The first metric for medication-related harm, which links safe prescribing of non-steroidal anti-inflammatory drugs in general practice and harm manifesting as admission to hospital due to gastrointestinal bleeding, has been published by NHSI. As further metrics for use in primary and secondary care are developed, the extent to which medicines are managed safely across our health system can be identified; and where preventable harms are identified, improvements can be made to reduce risks to patients.

However, the requirements of ‘Medicines without harm’ must not detract from the ongoing work of the healthcare professionals, including the medication safety officers who strive to achieve the safe use of medicines across the NHS on a day-to-day basis.

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