World Patient Safety Day is September 17. We’re joining individuals and organizations across the country and world to increase public awareness of and engagement in the importance of patient safety, including this year’s theme: medication safety.  

Medication is one of the most common interventions in healthcare for the treatment of disease and illness. However, it can and does cause serious harm and even death if it is improperly stored, prescribed, transcribed, monitored, or taken by a patient.

Medication errors are a leading cause of injury and preventable harm in healthcare systems.¹

• The Institute of Medicine Committee on Identifying and Preventing Medication Errors estimated "that about 1 medication error occurs per patient per day in hospital care.”²

• In the U.S., the Food and Drug Administration (FDA) receives more than 100,000 reports each year through MedWatch associated with a suspected medication error.

• Over the past 10 years, Oregon healthcare organizations have voluntarily contributed 790 "medication or other substance" adverse event reports to the Patient Safety Reporting Program.

Medication errors and medication-related harm occur because of system weaknesses and human factors like staffing shortages, burnout, and communication problems, that affect different stages of the medication administration process. The WHO Global Patient Safety Challenge: Medication Without Harm, a global initiative aimed at reducing the level of severe, avoidable harm related to medications, emphasizes the need to adopt a systems approach to effectively promote safe medication practices and reduce medication-related harm. The World Patient Safety Day 2022 campaign specifically calls on all interested individuals and organizations to take urgent action in key areas where the most patient harm occurs because of unsafe medication practices: high-risk situations, transitions of care, and polypharmacy.

What You Can Do

Your healthcare organization can invest in programs, policies, initiatives that support efforts to improve medication safety. Here are some resources to help you get started.

Use Tools and Best Practices

For Healthcare Professionals

Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices
An Agency for Healthcare Research and Quality (AHRQ) report that includes chapters on harms due to anticoagulants, diabetic agents and opioids, and reducing adverse drug events in older adults.

Medication Safety
AHRQ offers a list of patient education materials—including fact sheets, research, and government initiatives—for healthcare professionals to reduce the risks medication-related harm events. 

List of Confused Drug Names
An Institute of Safe Medication Practices (ISMP) list that contains look-alike and sound-alike (LASA) drug name pairs to determine which medications require special safeguards to reduce the risk of errors and minimize harm.

List of High-Alert Medications in Acute Care Settings
An ISMP list of high-alert medications to help determine which medications require special safeguards to reduce the risk of errors and minimize harm in acute care settings.

5 Moments for Medication Safety
A World Health Organization patient engagement tool that focuses on 5 key moments where action by the patient or caregiver can reduce the risk of harm associated with the use of medications.

For Patients and Families

ConsumerMedSafety.org
A website provided by ISMP to help consumers avoid mistakes when taking medicines.

Medication Safety: You and Your Pharmacist
A brief video created by Oregon State University and Pacific University (Oregon) Pharm.D students to highlight medication safety.

Attend the 19th Annual Northwest Patient Safety Conference

Join us for the Northwest Patient Safety Conference: Advancing Patient Safety in Today’s World, a two-day virtual event on October 18 and 19, 2022. The conference brings together healthcare professionals, providers, patients, families, and caregivers from all care settings for networking and engaging with industry thought leaders and others invested in improving the patient experience.

Participate in Oregon’s Patient Safety Programs

Patient Safety Reporting Program (PSRP)
PSRP collects and analyzes information from Oregon’s healthcare facilities about patient harm events. We share the lessons learned to support facilities in improving care and preventing future harm.

Early Discussion and Resolution (EDR)
EDR helps connect patients who experience harm and their healthcare provider so they can speak candidly about what occurred, work toward reconciliation, and contribute to safeguarding others from similar harm.

References

1. Aitken M, Gorokhovich L. Advancing the Responsible Use of Medicines: Applying Levers for Change. Parsippany (NJ): IMS Institute for Healthcare Informatics; 2012 (https://ssrn.com/abstract=2222541, accessed 26 July 2019).

2. Institute of Medicine, Preventing Medication Errors (Washington, DC: The National Academies Press, 2007), 111. doi.org/10.17226/11623.