Navigating Patient Safety: Tackling Medication Errors

This text is based on the white paper The Urgent Need to Reduce Medication Errors in Hospitals to Prevent Patient and Second Victim Harm, Originally published by the European Alliance for Access to Safe Medicines in 2022

In the complex landscape of healthcare, a pressing concern has emerged:  medication errors. The European Medicines Agency sheds light on varying rates of these errors in hospitals, raising serious questions about patient safety. Surprisingly, these errors are more common than rates for traffic accidents, breast cancer, or HIV. The economic toll is substantial, with the WHO estimating a staggering USD42 billion global cost each year. Recognizing the gravity of the situation, healthcare professionals and stakeholders have formed the European Collaborative Action on Medication Errors and Traceability (ECAMET) Alliance.

Comprising 21 organizations, the ECAMET Alliance is working towards consistent and harmonized practices to combat medication errors in European hospitals. A recent pan-European survey among hospital pharmacists, commissioned by the alliance, uncovered a notable lack of implementation of medication traceability systems. Crucial areas for improvement, identified by pharmacists, include electronic prescription, error surveillance, and barcode administration systems. The survey also highlighted obstacles such as insufficient funding, human resources, and a shortage of trained staff.

It is imperative to note the robust recommendation for the implementation of medication traceability systems within healthcare, backed by compelling clinical evidence. These systems, leveraging advanced technology, aim to standardize medication practices, particularly during the preparatory stages, thereby mitigating variability.

Comprising electronic prescriptions integrated with sophisticated functionalities, automated dispensing cabinets, electronic preparation systems ensuring precise medication dosages, barcode systems for accurate patient dosages, and intelligent pumps equipped with safety features to avert programming errors, these traceability systems underscore the necessity for comprehensive and interconnected solutions.

Of notable significance are electronic prescription systems, especially those utilizing Computerized Provider Order Entry (CPOE), which play a pivotal role in error reduction. CPOEs, with integrated features such as allergy alerts, interaction checks, and dosage recommendations, stand as instrumental tools in minimizing prescription errors. Surprisingly, while a significant 94% of hospitals possess electronic prescription systems, merely 20% integrate them with clinical decision support, and approximately 50% extend their availability to critical patients in specific areas. Furthermore, there is a conspicuous lack of seamless integration with broader hospital systems.

Automated drug cabinets, when synchronized with CPOE, emerge as efficacious in diminishing medication errors, curtailing costs, and enhancing operational efficiency. However, their deployment remains limited, particularly in critical care units, with only 16% equipped with barcode systems for the verification of drug selection before dispensing or replenishing cabinets.

Beyond dispensing, the preparation of medications is a critical aspect. While central pharmacies boast adequate resources, a substantial volume of medications is prepared outside these centralized hubs. Survey data reveal that a mere 19% of medications are prepared within central pharmacies, exhibiting variances in different hospital areas.

The overarching conclusion emphasizes the paramount need for comprehensive medication traceability systems. The observed challenges underline the urgency for heightened integration efforts and the adoption of advanced technology within healthcare settings. This collective effort aims at fortifying patient safety and curbing medication errors, aligning with the recommendations set forth by healthcare experts.

In response to these findings, the ECAMET Alliance urges stakeholders to integrate medication safety into key European healthcare strategies, allocate investments in medication traceability systems, and encourage the exchange of best practices. The recommended measures to prevent medication errors include fostering a safety culture, improving communication, conducting regular multidisciplinary training, utilizing accreditation systems, and leveraging technological tools.

Medication errors have far-reaching consequences, affecting patient well-being, healthcare professionals' morale, and imposing significant financial burdens. The emphasis on traceability systems emerges as a pivotal strategy to reduce errors, simplify processes, and enhance overall patient safety. The challenges highlighted by the survey underscore the immediate need for collaborative efforts among European healthcare stakeholders to implement effective solutions, ensuring a safer and more reliable medication management process across hospitals.

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