Medication is the most common therapeutic intervention and our work as pharmacists, pharmaceutical assistants and technicians, aims to ensure safe, effective and efficient use of medicines. The IPU Review will carry a series of articles on medication safety over the coming months, to provide regular practice focused updates to aid you in ensuring medication and patient safety in your practice.

The aim of this series is to provide updates on issues such as:

• New or updated product safety notices and any potential actions required;
• Learnings from practice, with information coming from a range of bodies including the HPRA, HSE national medication safety programme, WHO, the Irish Medication Safety Network (IMSN), the PSI and others, as appropriate; and
• Any upcoming medication and patient safety events and initiatives.

In the first article in this series, Ciara Kirke, medication safety lead with the HSE, provides an overview of the WHO Global Patient Safety challenge, ‘Medication Without Harm’.

‘Medication Without Harm’

Reducing medication-related harm and improving medication safety is the focus of the current WHO Global Patient Safety Challenge, ‘Medication Without Harm’. This is the third challenge, following on from the very successful ‘Clean Care is Safer Care’, and the ‘Safe Surgery Saves Lives’ challenges.

Why?

Medication is a leading cause of avoidable harm in healthcare systems across the world. Irish research tells us:

• Adverse drug events (ADEs) account for 10 per cent of general emergency admissions in those aged 65 and over;
• 20-53 per cent of community-dwelling over 65s are prescribed at least one potentially inappropriate medicine (PIM), and 38-45 per cent had at least one potential prescribing omission;
• Hospitalisation is associated with increased polypharmacy and less appropriate medication, and is the factor most associated with inappropriate prescribing in community-dwelling older adults;
• On admission to hospital, unintended discrepancies are present for 16-25 per cent of medications and 86 per cent of people; and
• Discharge prescribing error or miscommunication is present for 65-83 per cent of patients, and 69 per cent of discrepancies remain unresolved 10-14 days post-discharge.

At least half of this medication-related harm is potentially preventable.

What does the WHO think we should do?

The challenge goal is to reduce serious avoidable medication-related harm by 50 per cent over five years. The WHO framework identifies three key areas for priority action and four domains in which actions are needed.

Figure 1: The Strategic Framework of the Global Patient Safety Challenge

This image is available at strategic-framework-medication-without-harm86c06fafdf0b4294bd23ec9667dfb95d.pdf (who.int)

Three key priority areas for urgent action identified by the WHO target the most at-risk processes and patient groups:

1. Improve medication safety at transitions of care: High levels of discrepancies exist across transitions of care in Ireland, and this contributes to a substantial burden of harm and to inefficiencies in healthcare delivery. Effective actions to improve safety at transitions include pharmacy-led medication reconciliation. Technology can assist these processes. Patient empowerment including patient-held medication lists are recommended. You can download these lists on the HSE ‘Safer Meds’ webpage (available at hse.ie > Our Organisation > National Quality and Patient Safety Directorate > Medication Safety Resources);
2. Optimising management and patient understanding of high-risk medicines: Most serious harm is associated with limited classes of ‘high-risk’ medication. This denotes medication where harm is more likely to result with its use or omission. These groups include the APINCH medicines:

It should also be noted that anti-inflammatory drugs (NSAIDs) and diuretics are also associated with a substantial burden of harm; and

3. Reduce inappropriate polypharmacy: Polypharmacy, the use of multiple medicines, has been described as a significant public health challenge. In Ireland, the number of people 65 years or older taking ten or more medicines quadrupled from 5.4 per cent to 21.9 per cent from 2002 to 2012, the most recent data available. While increasing use of medicines is appropriate and essential as more people live with multiple long-term conditions, increasing polypharmacy is associated with lower adherence, risking treatment failure, and higher rates of medication-related harm, including drug–drug interactions, falls, adverse drug reactions, cognitive impairment and poor nutritional status. There is a financial and climate impact of inappropriate medicines use. Polypharmacy also adds complexity at transitions of care, increasing the likelihood of discrepancies.

What can we do?

The pharmacy team is in a powerful position to think globally and act locally, supporting patients and staff to reduce potential medication-related harm. The pharmacy team can promote patient safety at each of the key steps highlighted by the WHO:

Figure 2: Key Steps for Ensuring Medication Safety (available p. 8 at

https://www.who.int/docs/default-source/patient-safety/who-uhc-sds-2019-11-eng.pdf)

1. Screening prescriptions for duplication, appropriate dosage, interactions and other safety issues;
2. Reviewing medication to ensure that all medicines are appropriate, safe and beneficial to the person, and that they are able and willing to take them. This can occur routinely as part of the dispensing process as well as when conducting medicines reviews, for example, in nursing homes;
3. Ensuring high standards of accuracy in dispensing with independent checking, which has been shown to intercept 95 per cent of dispensing errors;
4. Ensure the person is able and willing to take the medicines as directed. Support people to know their medicines and keep a list, check the details and ask you anything they’re unsure about (Know, Check, Ask); and
5. Engage with your customers to support them with keeping a medicines list and bringing it to appointments and admissions. Engage with colleagues in healthcare settings to clarify medicines lists.

Key points

• The current World Health Organisation’s Global Patient Safety Challenge, ‘Medication Without Harm’, aims to reduce avoidable medication-related harm by 50 per cent;
• People at greatest risk of harm are those requiring high-risk medicines, with polypharmacy and those moving across transitions of care, making these the priority areas to focus on; and
• Empowered patients and the public, empowered healthcare professionals, robust, safe processes and systems, and taking action to reduce the risk of error, can help achieve this goal.

Definitions

The World Health Organisation (WHO) has outlined on many occasions that medication safety is a focus area for improvement. To support community pharmacists in this area, the IPU has launched the Medication Safety Section in the IPU Review. Here are some of the concepts that will be explored:

Adverse event: An adverse event is an untoward medical occurrence after the exposure to a medicine, which is not necessarily caused by that medicine.

Adverse reaction: An adverse reaction is a response to a medicinal product which is noxious and unintended. This includes any harm following an overdose, misuse or error regarding that medicinal product.

High-risk medicines: High-risk medicines are those medicinal products that have a higher risk of causing significant patient harm or death when used in error. Some hospitals in Ireland use the acronym “A-PINCH” to raise awareness about high-risk medicines. This acronym stands for Anti-infective agents, Potassium, Insulin, Narcotics and sedatives, Chemotherapy, and Heparin and other anticoagulants.

LASA — Look Alike, Sound Alike, medicines: There are many look-alike or sound-alike drugs that could result in medication errors. These groups of medicines are commonly referred to as LASA or SALAD. According to the World Health Organisation (WHO), medication errors and unsafe medication practices are leading causes of patient harm globally. LASA medicines are a well-recognised cause of medication errors that are due to orthographic (look-alike) and phonetic (sound-alike) similarities between medicines, which can be confusing.

Polypharmacy: Even though there is no set definition for this concept, polypharmacy is interpreted as the concurrent use of five or more medications, including over-the-counter medicines, prescription medicines and/or traditional and complementary medicines.

Transition of care: Transition of care are the various points where a patient moves to, or returns from, a particular physical location, or makes contact with a healthcare professional for the purposes of receiving health care. Therefore, during the patient journey there is a flow from primary care settings to secondary care settings and vice-versa. Throughout the transition of care, there is a high probability that the patient’s medication (if there was any), may change between the different stages of the transition of care.

Cyclizine and dexamethasone mix-ups

There have been sporadic reports from hospitals of patients mixing up cyclizine and dexamethasone tablets. Patients on regular chemotherapy often receive a prescription for cyclizine tablets (on an ‘as required’ basis), at the beginning of their treatment for nausea and vomiting. Certain chemotherapy regimens require patients to take a high dose of dexamethasone tablets during each cycle. In some cases, patients have mistakenly taken all of their cyclizine tablets instead of dexamethasone. In many of these cases, the patients have been admitted to hospital for management of side-effects and observation.

A common theme running through these incidents is that the patients were already several cycles into their treatment, leading to the conclusion that complacency is a factor in the mix-ups. It is also highly likely that the similar appearance of both products contributes to the problem. Generally, cyclizine tablets and dexamethasone tablets are dispensed in brown tablet vials and the tablets themselves are broadly similar in appearance.

Suggested ways to reduce the risk of patients selecting the wrong medicine are:

1. Dispense the two medicines in different quantities, for example, dispense the cyclizine tablets in a smaller quantity, different to the dexamethasone amount;
2. Highlight the potential for confusion to patients when they are collecting their medicine, particularly when they have already been through a few cycles of treatment; and
3. Mark the label of one container with a distinctive colour to visually distinguish the two products.

It can be useful to have contact details for your local oncology department or oncology pharmacist, so you can flag this issue to them, should it occur in your practice.