What can we do to reduce medication errors?

Medication-related patient safety is a multi-layered global problem detailed in the movie (OVER)DOSE – How can we prevent medication errors? which aired on 29 June 2021. Medication challenges are caused by a lack of safety culture, and from medication names that look or sound alike, but are intended for different indications. Additional risks come from a lack of digitalisation, a poor implementation of IT systems, or a lack of traceability for a patient’s medication due to insufficient interoperability among the healthcare institutions in which the patient is being treated. At the same time, new hopes lie in better decision-support systems which give patient-specific recommendations and are less burdensome for doctors.  

Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated by the WHO at $42 billion USD annually. In England, medication-related errors cause 1,700 deaths every year according to research by BMJ Quality & Safety, and the estimates for the United States are around 100,000 deaths annually based on different research. However, such estimates can be unflattering, since many of them are based on research which is ten or twenty years old. In the last two decades, technologies have brought along significant improvements in terms of reducing medication errors, especially when implemented and adopted well. However, buy-in on the part of clinicians in the implementation stage is crucial, as hospitals can otherwise end up with an increase in medication errors, and the kinds of medication errors that can result in severe patient harm are an ever-present danger in medicine.

With the rise of AI, the promise is that drug development and decision-support systems will become more efficient because they will be able to digest and take into account many more aspects of a patient’s treatment and specifics. In the end, on the hospital level, medication safety can be improved if: the hospital has a strong overall vision and strategy for patient safety, good practices are reinforced across healthcare, there is enough funding and technologies to support it, and also if patients become more involved in shared decision making – and these were just a few points mentioned by the speakers in the documentary. 

The documentary (OVER)DOSE was filmed with ten speakers from six countries around the world and shows that while healthcare systems across the world differ, the same organisational challenges and causes for medication errors are present in different geographies.

The movie’s premiere, which was on 29 June, was followed by an expert panel discussion, where six speakers from five countries commented on the movie.

Robert Johnstone, Board Member of the European Forum for Good Clinical Practice (EFGCP) and International Foundation for Integrated Care (IFIC), spoke from the patient’s perspective. “Even a good physician will listen to you, but maybe not respect what you’re saying. I’ve worked a lot with patient organisations, and I see the value of patient organisations for not only informing patients but also working with physicians and hospital administrators to make services better for everybody,” Robert Johnstone said. Patients are often intimidated since they only go and see doctors when their health status is severely impacted. “Very often they may be very ill, very tired, very intimidated, and the physicians and all the healthcare staff can do many good things to support them give them confidence, encourage them to participate, and enable them to better adhere to whatever treatment regime is agreed, especially if they’re involved in the process of choosing a regime,” he added.

Katrina Azer, Pharmacist, Patient Advocate, and Board Member of the Pharmacy Council of New Zealand, emphasised that medication-related errors have a few causes that could be mitigated. Healthcare organisations need to adopt good clinical governance principles, be accountable and responsible for the healthcare that is provided to their patients, and make patient care the top priority. “I quite like a quote by Professor Liam Donaldson: ‘To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.’ One of the downsides that I’ve seen from complaints is when clinicians fail to take responsibility for an error that was made, and fail to develop processes and frameworks to mitigate the error in the future."

Alexander Jankuloski, CEO at Kuwait Hospital mentioned that, from the leadership perspective, there is a very fine line between holding someone accountable and being accused of enforcing a blame culture.

Yu-Chuan Jack Li, a researcher of artificial intelligence (AI) in medicine and medical informatics, a practicing dermatologist, and the Editor-in-Chief of BMJ Health & Care Informatics mentioned that medication errors are a healthcare system’s problem and we need to use technology to make healthcare simpler. “We are putting healthcare professionals and patients in a very complicated environment, and the environment is not getting simpler; it’s getting more complicated over time, because of new technologies, new drugs, and new ways of treating patients. We are already reaching a tipping point where, if we don’t use a lot of the information technology in AI, we are bound to make a lot of mistakes.”

Hicham Naim, Global Head of Integrated & Personalized Patient Care for Takeda, who commented on the movie from the Pharma Industry’s perspective, mentioned that no medicine is safe and that we need to be aware of that as patients or clinicians. He agreed that look-alike and like-sounding medication names are a serious healthcare problem, while also emphasising that patients are the most underutilised stakeholders in healthcare.

Stefan Siekierski, nurse, Electronic Prescribing Project Manager, and Better Delivery Manager for the UK & IE, indicated that if an IT system is not well-accepted by clinicians, the hospital can face the need for the withdrawal of the whole system, simply because the implementation was not done in collaboration with the end-users. Additionally, the support provided after implementation is crucial for the long-term positive impact of a system.  

During the second round of questions that highlighted solutions to mitigate medication errors, Katrina Azer pointed out that errors are often a systemic problem, and that the search for solutions needs to be a carefully thought-out process. “One of the important things is design thinking – ensuring that the solutions we put in place are user-friendly, both for the clinician and for the end-user, or the patient, through adopting design-thinking concepts. Empathy for and understanding the needs of the patient, assessing all sides of the problem that we’re trying to address, and being solution-focused; experimenting and collaborating with all the parties involved.” She also mentioned that healthcare professionals all too often work in silos. Good communication between teams underpins every aspect of good health care provision, whether it takes place through apps or through face-to-face communication.

Hicham Naim said that technology can never be the only solution to this problem. The Pharma industry doesn’t have all the answers, but it could make information about medications as clear as possible. Some already existing solutions addressing this issue include the use of QR or RFID codes on medications to access medication information and its origin as easily as possible.

When asked about his expectations regarding the use of AI in practice in the next ten years, Prof. Yu Chuan Jack Li said that he believes maximum dosing for paediatric patients should be easily available. In three to five years he believes that making choices could be simplified to a certain extent. “The environment needs to be made easier,” he again emphasised.   

Alexander Jankulovski expressed criticism towards current medical education, which does not in any way follow the fast-paced progress being made in technology development, and that this is one of the things which should be improved. As an example of good practices in improving medication safety, he spotlighted the systems where electronic patient records are connected, and thus enable doctors to see what was ordered regardless of the healthcare institution a patient visited.

Stefan Siekerski added that there is a lot going on about medication data interoperability in the NHS, which is building an infrastructure for the exchange of medication data that includes an Electronic Prescribing System (EPS). An EPS enables primary care physicians to send medication data to a pharmacy electronically, and the NHS also built an app for patients to see their own medications.  

Robert Johnstone concluded the discussion by emphasising that patients are probably the most valuable and most underutilised resource in the healthcare system. “Especially those of us with chronic problems – we have to keep going back to doctors. We don’t want to be seen as the problem. We want to be seen as part of the solution. And with appropriate training and support from well-funded patient organisations, patients can be good patients, asking high-quality questions, being active and positive participants in the decision-making process. We’re very happy to work with everybody. It’s for our own good, but you know, they need to listen to us and respect what we say and involve us in the processes, whether we’re talking about the prescriber, or whether we’re talking about the pharmacist; whether we’re talking about the design of the packaging, or the leafleting. So, really good communication between the patient and any sort of healthcare professional, with a willingness to involve us in good communication, will help with that patient buy-in, facilitate that adherence, and help the systems, whether they’re AI or manual systems, to develop learning about what works and what doesn’t work.”