World Patient Safety Day, September 17, 2022

September 17^th is the World Patient Safety Day. The theme chosen by the World Health Organization (WHO) for the 2022 edition is “Medication without harm”. On this occasion, we mark the importance in raising awareness on major issues affecting quality and safety of care – area of focus which falls within HAS’s scope of action.

WHO states that “medications sometimes cause serious harm if incorrectly stored, prescribed, dispensed, administered or if monitored insufficiently. Unsafe medication practices and medication errors are a leading cause of avoidable harm in health care across the world. Medication errors occur when weak medication systems and human factors such as fatigue, poor environmental conditions or staff shortages affect the safety of the medication use process. This can result in severe patient harm, disability and even death. The ongoing COVID-19 pandemic has significantly exacerbated the risk of medication errors and associated medication-related harm… “

In this context and for this very occasion, HAS highlights anew for healthcare professionals a selection of work and tools designed to contribute to drug management safety.

Avoid curare medication errors by appropriate storage

Curare medication errors represent 11% of all medication-related errors among care-related serious adverse events database  (errors related to health products received at the HAS from March 2017 to December 31, 2019).

To help professionals avoid these types of errors, the HAS published “Focus on patient safety  - Curare storage : not so uncommon mistakes” in May 2022.

This Focus aims:

• To alert healthcare professionals as to the recurrence of treatment-related serious adverse events due to non-observance of good storage practices,
• To raise awareness among healthcare professionals as to the absolute control of good curare preservation, storage, preparation and administration practices,
• To reinforce acquisition of the 5 rights rule and good high-alert medicinal product administration practices.

Prevent dose errors by avoiding calculation errors

Adverse events related to medicinal products are the third most common cause behind the serious adverse events reported. Among these medication errors, dose errors are the most commonly reported type of errors with dose errors related to incorrect dose calculation being over-represented 

To help professionals prevent these errors, the HAS published a “focus on patient safety”

”Medicinal product dose calculation. The rule of three must remain the rule." in January 2022.

This information sheet highlights an apparent inability for a majority of health professionals to correctly perform the fundamentals of pharmaceutical calculations (units of mass, volume, time, conversions, concentrations, dilutions, flow rates, etc.), which includes the rule of three.

In addition, verification by a second person was found to be non-systematic for drugs known to be of high-risk; the absence of systematic control equally extended to task interruptions.

Other “focus on patient safety” dedicated to medication errors are available:

• Accidents related to a high-risk medicinal product. Who says potassium (KCl) says maximum vigilance”

• “High alert medications. Underestimating the risk is risky”

The "Focus on patient safety collection covers other safety topics and is regularly updated. Designed for professionals, these information sheets  are based on real situations and selected from national care-related serious adverse events reporting databases (and/or doctors’ accreditation feedback database) to help draw lessons and develop new benchmarks.

Limit task interruptions when administering medication

Task interruptions during the administration of medication are minimized as being a part of everyday practice, in addition to being habit-forming. However, a significant number of task interruptions represent at-risk situations for error.

Following publication of its 2013 guide “tools for safety and self-assessment of drug administration”, the HAS provides professionals with a series of tools:

• a guide on everything you need to know about task-interruption during medication administration
• a film for educational purposes, produced by professionals, to illustrate situations associated with task-interruption when administering medication
• an audit kit to conduct targeted audits
• a user manual for lessons learned from feedback from 7 regions and a 4-page guide to better understand key elements (in collaboration with the OméDITs, 20 teams benefited from support using HAS media) .

Prevent medication errors by implementing medication reconciliation

Medication reconciliation is a process aimed to prevent and intercept medication errors and ensure continuity of patient medication management in a care pathway.

The HAS published an update to a guide published in February 2018 “Implementing medication reconciliation in healthcare establishments”. Its purpose: raise awareness and support professionals and patients in medication reconciliation, by promoting the gradual implementation of this approach and facilitating its deployment by providing tools and scenarios tested by health professionals. In March 2019, the HAS also published "Drug reconciliation in oncology".

Reduce errors associated with health products, specifically medications

In 2020, the HAS published a body of work on health product-related errors declared in the serious adverse events database and more specifically on drugs. Its purpose: to better understand why drugs continue to remain frequently implicated in the occurrence of serious adverse events despite widespread knowledge.

It also makes it possible to identify levers – existing or new – that should be mobilized for greater safety in drug management. It is from this analysis that recurrent serious adverse drug events were identified. Thus, it was deemed important to raise awareness among professionals on the nature and purpose of the HAS patient safety flashes in drug management.

Inform the patient and follow good practices in medication use

The accreditation framework for healthcare institutions places particular emphasis on risk associated with medicines. It includes, for example, the following criteria:

Patient-related:

1.1-09 Prior to discharge, the patient is informed of monitoring instructions for prescribed drugs.

Healthcare team-related:

- 2.2-07 Patient drug management safety benefits from medication reconciliation
- 2.3-03 Teams follow good prescribing and dispensing practices
- 2.3-04 Teams follow good drug delivery practices
- 2.3-06 Teams control the use of high-risk drugs
- 2.3-08 Teams control the risk of discontinuity in medication management of vulnerable patients upon discharge

Safe patient self-administration of medications in healthcare establishments

Patient self-administration of medications during hospitalization

Following regulatory changes and a recognition to align with patient commitment to care, the HAS recently published a set of recommendations on patient self-administration of medication treatment. The benefits gained are multiple, such as:

• increased patient autonomy and commitment to safety of care: allowing self-administration of prescribed medications, i.e., "right medication, right dose, right time, right route of administration over time”.

• strengthen multi-professional teamwork.

• reduce the risk of error upon patient discharge by ensuring continuity of care in medication management.

• improve patient understanding of medication therapy, thereby strengthening patient compliance.

• safeguard situations that carry a risk in medication management.

Additional works on the safety of drug management are expected to be published soon.

Find out more about World Patient Safety Day on 17 September 2022 by visiting the World Health Organization

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