Federal Ministry of Health

DG of Quality, Development and Accreditation

Medication Safety Policy Guide for Hospitals

6th of August 2015

An introduction ..

Prepared by:
Dr. Ayda Abdien
Head of Programs Directorate
Overview

 Introduction to Patient Safety

 Introduction to Medication Safety

 Short Film “Learning from Error”

Conclusion
What is Patient Safety?
 A new healthcare discipline that aims at the
avoidance and prevention of adverse
events stemming from the process of
healthcare.

 It emphasizes reporting, analysis, and

prevention of these events. (IOM,1998)

“Continuous Learning” is KEY

What is an Adverse Event?
 Is a harmful and undesired event that occurs
during provision of healthcare

 Example medical error, baby abduction, fall

 Different types

 Most grave is a Sentinel Event which ends

with either disability or death to the patient
Why Patient Safety?
Let’s talk numbers…..

 44,000 – 98,000 people die

each year from medical
errors that occur in
hospitals.

IN USA ALONE!!!
(IOM,1998)
Healthcare Deaths

More than deaths from motor vehicles accidents,

breast cancer, and AIDS combined—

making medical errors the fifth leading cause of

death

Annual cost
37 to 50 billion dollars
 BMJ 2001;322:517–90

03/08/2023 7
 Canadian Study

Interpretation: The overall incidence rate of AEs of 7.5% in

our study suggests that, of the almost 2.5
million annual hospital admissions in Canada similar to
the type studied, about 185 000 are associated with an
AE and close to 70 000 of these are potentially
preventable.
CMAJ2004;170(11):1678-86

03/08/2023 8
Eastern Mediterranean Region
• On average, 4 million individuals from our Region are
harmed every year in health care facilities
• Results of a 3 years EMRO research project (2005–
2008) showed that :
 AE rate for selected hospitals in EMR is 8.2%
 40% of cases experienced death or permanent
disability
 50-80% of cases were Potentially preventable

Riham El-Asady, Health Care Delivery Unit, WHO/EMRO, August,

2008

03/08/2023 9
 Adverse Event Rate: 5.5%
- 83% : Preventable
- 39% : Permanent
disability/death

SUDAN
 Global Situation

WHO calls Patient Safety an endemic concern

One in every 10 patients are harmed from healthcare
 How hazardous is healthcare?
DANGEROUS REGULATED ULTRA-SAFE
(>1/1000) Health (<1/100K)
100,000 Care
Driving
Total lives lost per year

1/2
10,000

1,000
Scheduled
Chartered Airlines
100
Flights European
Mountain
Railroads
10 Climbing Chemical
Bungee Nuclear
Manufacturing Power
Jumping
1
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality

03/08/2023 12
What was found to be the Cause?

Poorly structured
systems rather than
individual error
Goal to improve Patient Safety

Open

Learning Blame

Non Punitive
 Strike a balance
 

Non punitive
Accountability
Open learning
What happened as a result?
 WHO declared Patient Safety a global concern

 2002: World Health Assembly’s resolution

“Pay the closest possible attention to Patient Safety”

 2004: launch of
What where the priority areas identified?

1. Medication errors
2. Injection Safety
3. Failure to use or act on diagnostic test
4. Wrong site surgery
5. Post operative complications
6. Use of inappropriate or outmoded diagnostic test
7. Transfusion errors
8. Healthcare associated infections
9. Failure to diagnose
10. Wrong communication procedures
 Medication Safety
 Medication safety means the patient get the 5 rights of
medicine

Medicine Dose

Patient

Time Route

June 2015 EMRO Tunisia 18

 Adverse Drug Event
A negative consequence of medication use encompassing
both mistakes that result in harm to the patient

Medication errors Adverse drug reaction

any preventable event that may cause
or lead to inappropriate medication
use or patient harm while the
medication is in the control of the
health care professional, patient, or
consumer.
unexpected harm arising from a
justified action where the correct
process was followed for the context
in which the event occurred. For
example: allergic reaction
Medical Errors by type
100%

90% 20% Medication Ordering/

Errors 39%
Prescribing
80%

70%
38% Administration
60%

50%
12% Dispensing
40% 80% 11% Transcribing
Other
30%

20%

10% Leape, et al

0%

Photo credits: PFPS Thailand

EMRO study: Type of error related to occurrence of
adverse event

Wilson R M et al. BMJ 2012;344:bmj.e832

Factors associated with medication errors

 Medications with similar names

CHEMOTHERAPY:
CARBOplatin – CISplatin
PACLItaxel – DOCEtaxel
vinCRIStine – vinBLAStine
Conventionals – Liposomals
(paclitaxel, doxorubicin, daunorubicin, cytarabine)
DACTINOmycin- DAUNOrubicin
DOXOrubicin - DAUNOrubicin

or similar packaging
Ranitidine/Midazolam
 Use of inappropriate abbreviations

Unacceptable Acceptable
 IU  International Units
 MgSO4  Magnesium Sulfate
 MS  Morphine
 MSO4  Morphine Sulfate
 QD, Q.D., q.d., qd  Everyday
 QOD, Q.O.D, q.o.d., qod  Every other day
 U or u  Units or units
 X.0 mg (zero after  Use X
decimal point) mg
 Cont…
 Medications that are not commonly used or prescribed
 Heavy workloads
 System complexity
 Language differences
 Lack of training & competency assessment
 Lack of experience
 Distractions
 Work environment

The most frequently cited cause

Ineffective communication especially during handoffs
Medication Management
 Medication management covers the whole process

selection procurement storage

prescribing dispensing administration

 Errors in any one of these steps can have serious

consequences for the patient.
 Prescribing/ordering
 Wrong drug, dose, or
route can be ordered
 Patient has known
allergies.
 Workload
 Illegible and/or
incomplete orders
 Orders for
contraindicated
medications,
inappropriate doses
  
Transcribing
 Incorrectly filling the order

Dispensing

 Dispensing the wrong drug

 Strength, dosage form and quantity
 Labeling drugs with the wrong directions
 Legal validity and clinical safety
 Controlled drug documentation
 Medication administration
 Miscommunication
 Wrong (time, rate, dose, or route)
 injectable drugs most often the problem
 Overdose
 Name confusion
 Similar or misleading labeling
 Human factors (e.g., knowledge or Performance deficits)
 Inappropriate packaging or device design.
How do accidents occur?
“Swiss Cheese Model”

Defenses
System
Opportunity
for failure System

System

System

ACCIDENT
Patient Medication Safety 29
 Strategies/Goals
Improve the effectiveness of communication
Especially Verbal & telephone orders

Identify and, at a minimum, annually review a list of

look-alike/sound-alike drugs used in the hospital.

Standardize and limit the number of high drug concentrations

available in wards.

Label all medications and medication containers

Reconcile Medications Across the Continuum of Care

Lets not forget: No one is Immune
First message of our journey
Patient Safety doesn’t need to be a top
priority, it should be the foundation of the
high quality
healthcare we provide

Patient Safety First

 Learnings of
Swiss Cheese Model
 Systems that rely on error-free performance are doomed to
failure

 Humans make mistakes

 Continue to strive for perfection but realize humans are not

perfect
 How?
1. Educate before you medicate
(at all levels)

2. Keep patient history and

records complete

3. Limit access to high hazard

drugs
 Cont….
4. Use policies, procedures and protocols especially
for high hazard drugs

5. Use unit-dose drug systems

6. Avoid abbreviations

7. Standardize drug packing, labelling and storage

Thank you