OMS Global Initiative 2017

«We all hope to get better, not worse, when we take a drug»





Millions Damages to People


Millions Worldwide Cost per year

Press release March 29, 2017 | GENEVA / BONN - The World Health Organization (WHO) today launches a global initiative to halve serious and preventable drug-related harm in all countries over the next five years. The Global Patient Safety Challenge on drug safety aims to address deficiencies in health systems that lead to medication errors and, as a consequence, serious harm. The initiative establishes how to improve the prescription, distribution and consumption of medicines and calls the attention of patients to the risks associated with their inappropriate use. In the United States of America alone, medication errors cause at least one daily death and damage to approximately 1.3 million people a year. Although low- and middle-income countries are estimated to have drug-related adverse event rates similar to those of high-income countries, the number of years of healthy life lost is roughly double. Many countries do not have reliable data, so a compilation of them will be carried out within the framework of the initiative. The global cost associated with medication errors is estimated to be US $ 42 billion per year, or almost 1% of global health spending. "We all hope to get better, not worse, when we take a drug," said Dr. Margaret Chan, WHO Director-General. “In addition to the human cost, medication errors place a huge and unnecessary burden on health budgets. Preventing mistakes saves money and lives ”. At some point in our lives we all take some medicine to prevent or cure a disease, but sometimes, if we do it incorrectly, without proper follow-up or as a result of an error, accident or communication problem, the medicine can cause harm. serious. Both healthcare personnel and patients can make mistakes when ordering, prescribing, dispensing, preparing, administering or consuming the wrong medicine, in the wrong dose or at the wrong time, which can cause serious harm. Now, all medication errors can be avoided. To do this, and to avoid subsequent damage, systems and procedures need to be put in place so that the correct patient receives the correct medication in the correct dose, by the correct route and at the correct time. Medication errors can occur because healthcare professionals are tired, overstaffed or understaffed, poorly trained, or incorrect information communicated to patients, for example. Any one of these reasons, or a combination of them, can alter the prescription, dispensing, consumption and monitoring of medicines, which can lead to serious harm, disability and even death. Most damage occurs when the organization and coordination of healthcare systems fails, particularly when multiple healthcare providers are involved in caring for a patient. The safest environment for healthcare is achieved when there is an organizational culture that consistently applies best practices and avoids attributing blame when errors occur. The initiative calls on countries to take priority measures in time in relation to the following key areas in order to reduce medication errors and harm to patients: drugs with a high risk of causing harm if they are misused, patients taking multiple medications for various diseases and conditions, and patients being referred from one care to another. The actions planned in the initiative will focus on four areas: patients and the public, health professionals, medicines as products, and medication systems and practices. The goal of the initiative is to improve each of the phases of the medication process, including prescription, dispensing, administration, monitoring and use. WHO intends to offer guidance and develop strategies, plans and instruments so that the most important thing in the medication process is the safety of patients in all health centers. "I've known people for years who have lost loved ones to medication errors," says Sir Liam Donaldson, WHO Envoy for Patient Safety. “Their stories, their dignity, their integrity and the way they have accepted situations that should never have happened is something that has deeply moved me. This initiative should be dedicated to all those who died from unsafe care. This is the third time that WHO has organized a Global Challenge for Patient Safety: in 2005 it celebrated the initiative on hand hygiene "Clean care is safer care", and in 2008 the initiative "Safe surgery saves lives ». Media contact Simeon Bennett

Communications DepartmentOMS

mobile phone : +41 79 472 7429 Phone (office): +41 22 791 4621 Email: simeonb@who.int

Reference source: OMS World Health Organization

Colombia 2018 International Quality Symposium

International Symposium on quality and Patient Safety

2018 - Colombia Quality and Patient Safety









In Colombia there is no study to establish this situation. However, it is estimated that on average ten out of every hundred patients who enter a health institution for care suffer an adverse event, that is, unintentional damage, which can sometimes cause disability and even death.

Reference source: Newspaper Time

Medication Error

An error in the prescription, dispensing or administration of a drug, regardless of whether or not such errors have adverse consequences.1,2

You know what?

Medication errors

(1) James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013 Sep;9(3):122-8 (2) Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P, Metnitz PG; Research Group on Quality Improvement of European Society of Intensive Care Medicine; Sentinel Events Evaluation Study Investigators. (2006) Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med; 32(10): 1591-8


Parenteral medication errors are a serious safety problem in intensive care units (ICU) and are recognized as a high priority health care problem at the national and international level, in different ICU settings and different care systems 1,2,5 Errors have been associated with morbidity and mortality in the population that was already in critical condition.3,4
Most medication errors do not occur in emergency situations but during the performance of routine clinical tasks.5 The source of these errors can be at any stage of the process from the initial prescription of an infusion to its administration.11 This is a complex process12 and can lead to a wide range of different errors. 13-18

Medication errors Table

Fig. 1: Causes of medication errors and types of medication incidents they cause. One of the reasons adverse events are so common is that healthcare professionals are human and therefore prone to mistakes. The pivotal study by Wilson and colleagues found human error to be a significant factor. Most (81%) of the adverse events in their study were associated with one or more human factors, such as lack of knowledge, care, or attention.19 Of the events that were considered highly preventable, less than 1% were not associated with human error.19
There are main causes that increase the incidence of medication error5:

  • nursing workload (ratio of patients to nurses, occupancy rate, ratio of beds to nurse
  • unit size (complexity of the organization)
  • Similar Name / Similar Appearance Drug Labels

Consequences for health

Since the early 1970s, more and more studies of the number of parenteral medication errors have been published.4 The UK's National Patient Safety Agency has compiled figures showing the type of medication error incidents that occur. actually occur. More than 14,000 reports of incidents of injectable drugs were evaluated during 18 months.25 It was found that in more than 4,107 cases (28.9% of the total), the most frequent medication error was the wrong dose, concentration or frequency of the drug prescribed.
Errors and irregularities in IV drug preparation can have a wide range of consequences, from harmless to severe or fatal. The severity of the consequences depends on the drug in use and the specific factors of each individual case.

Consequences of medication error

Fig. 2: The consequences of medication errors range from harmless to serious and fatal.

Economic consequences

The financial costs of adverse events, in terms of additional treatment and prolongation of hospital stay days, are considerable. In Great Britain, the cost of preventable adverse events is approximately £ 1 Billion per year in lost bed days alone.22 The broader costs of lost work days, disability compensation and additional financial consequences are even higher.
The US Institute of Medicine report estimated that preventable medical errors result in total costs (including the expense of additional care caused by errors, lost income, decreased productivity at home and disability) of between $ 17 billion and $ 29 billion a year in U.S. hospitals.32
Research in Australia showed that the total costs of adverse events accounted for 15 , 7% of the total expenditure on direct hospital costs.33
Other significant damages associated with adverse events are human: that is, the harm suffered by the patient. Patients who experience an adverse event are between 4 and 7 times more likely to die than those who do not.33 Vincent al et al32 found that 19% of adverse events lead to moderate physical deterioration, 6% to permanent deterioration and 8% to death.22

Potential costs associated with risks

A cost assessment can be done, allocating costs to your related clinical treatment and what is involved in prolonging your hospital stay. The cost can be calculated by using the average daily cost of the expected clinical treatment.30,31 Fig. below shows the results of that calculation for selected examples of complications.

Potential Costs of Medication Error

Fig. 3: Estimation of possible additional costs as a consequence of complications caused by medication error. To facilitate the attribution of each complication to the cost calculation, severity levels were entered. UCIR: Intermediate Respiratory Care Unit
In the case of multiple serious complications that require complete treatment in the ICU during several days of hospitalization, a hospital can save between € 7,556 and € 56,670 per individual case.28-31

Preventive strategies

To avoid medication errors and effectively ensure the safe treatment of the patient, it is important to combine specific measures for the safe use of the product and the organizational measures related to its handling and administration.
As more successive controls are added, the security of the entire system is increased. Some concrete preventive strategies to implement in the clinical routine are described in the figure below.

Solutions to Medication Error

Fig. 4: examples to avoid medication errors Ensuring the 9 correct aspects should be the objective of all employees in the healthcare sector.26,27

9 Correct when administering medications

Scientific evidence

1 Döring M, Brenner B, Handgretinger R, Hofbeck M, Kerst G. (2014) Inadvertent intravenous administration of maternal breast milk in a six-week-old infant: a case report and review oft he literature. BMC Res Notes; 7:17 2 Manias E, Kinney S, Cranswick N, Williams A, Borrott N. (2014) Interventions to reduce medication errors in pediatric intensive care. Ann Pharmacother; 48(10): 1313-31 3 JCAHO. (2014) Tubing misconnections - a persistent and potentially deadly occurrence. Joint Commission on Accreditation of Healthcare Organizations, USA. Sentinel Event Alert; 53: 1-3. 4 Simmons D, Symes L, Graves K. (2011) Tubing misconnections: normalization of deviance. Nutrition in Clinical Practice; 26(3): 286-293. 5 Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P, Metnitz PG; Research Group on Quality Improvement of European Society of Intensive Care Medicine; Sentinel Events Evaluation Study Investigators. (2006) Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med; 32(10): 1591-8 6 Institute of Medicine (2007) 7 Edwards IR1, Aronson JK. (2000) Adverse drug reactions: definitions, diagnosis, and management. Lancet; 356(9237) :1255-9. 8 Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. (1995) Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA; 274(1): 29-34. 9 Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M, et al. (2000) Incidence and preventability of adverse drug events in nursing homes. Am J Med; 109(2): 87-94. 10 Nebeker JR, Barach P, Samore MH. (2004) Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. Ann Intern Med;140(10):795-801. 11 McDowell S, Mt-Isa S, Ashby D (2010) Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. Qual Saf Health Care; 19(4): 341-5 12 Fraind DB, Slagle JM, Tubbesing VA, Hughes SA, Weinger MB (2002) Reengineering intravenous drug and fluid administration processes in the operating room: step one: task analysis of existing processes. Anesthesiology; 97(1): 139-47. 13 Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R, Ardakani MT (2008) Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: an observational study. Aust Crit Care; 21(2): 110-6. 14 Ferner RE, Langford NJ, Anton C, Hutchings A, Bateman DN, Routledge PA (2001) Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. Br J Clin Pharmacol; 52(5): 573-7. 15 Garnerin P, Pellet-Meier B, Chopard P, Perneger T, Bonnabry P (2007) Measuring human-error probabilities in drug preparation: a pilot simulation study. Eur J Clin Pharmacol; 63(8): 769-76 16 Parshuram CS, To T, Seto W, Trope A, Koren G, Laupacis A (2008) Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ; 178(1): 42-8. 17 Cousins DH, Sabatier B, Begue D, Schmitt C, Hoppe-Tichy T (2005) Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care; 14(3): 190-5. 18 Cohen H, Robins ES, Mandrack M (2003) Getting to the root of medication errors: Survey results. Nursing; 33(9): 36-45. 19 Wilson RMcL, Harrison BT, Gibberd RW, Hamilton JD (1999) An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust; 170(9): 411-5. 20 Shane R. (2009) Current status of administration of medicines. Am J Health Syst Pharm. 2009; 66(5 Suppl 3): S42-8 12 21 Leape LL, Bates DW, Cullen DJ et al. (1995) Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA; 274(1): 35-43. 22 Vincent C, Taylor-Adams S, Chapman EJ et al. (2000) How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ; 320(7237): 777-81. 23 Reason J (1995) Understanding adverse events: human factors. Qual Health Care; 4(2): 80-9. 24 Dean B, Schaechter M, Vincent C, et al. (2002) Causes of prescribing errors in hospital inpatients: a prospective study. Lancet; 359(9315): 1373-8. 25 National Patient Safety Agency (2007) 26 Elliott M, Liu Y. (2010) The nine rights of medication administration: an overview. Br J NursMar 11-24;19(5):300-5. 27 Smeulers M, Verweij L, Maaskant JM, de Boer M, Krediet CT, Nieveen van Dijkum EJ, Vermeulen H. (2015) Quality indicators for safe medication preparation and administration: a systematic review. PLoS One. 2015 Apr 17;10(4):e0122695. doi: 10.1371 28 Taxis K, Barber N,(2003) Etnographic study of incidence and serverity of intravenoius drug errors.BMJ 326:684 29 Dean BS, Barner ND, (1999) A validated, reliable metohd of scoring the severity of medication errors. Am J Hosp Pharm 56 : 57-62 30 Gianino MM, Vallino A, Minniti D, Abbona F, Mineccia C, Silvaplana P, Zotti CM, (2007) A method to determie hospital costs associated with nosocomial infections. Ann lg 19(4) : 381-392 31 Bertolini G, Confalonieri M, Rossi; Simini B, Gorini M, Corrado A, (2005) Cost of the COPD. Differences between intensive care unit and respiratory intermediate care unit. Res Med 99: 894-900 32 Kohn L, Corrigan J, Donaldson M (2000) To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press, ISBN: 9780309068376 33 Ehsani J, Jackson T, Duckett S (2006) The incidence and cost of adverse events in Victorian hospitals 2003-2004. Med J Aust 184(11): 551-55 www.ncbi.nlm.nih.gov/pubmed/16768660 34 James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013 Sep;9(3):122-8 Research Author: www.bbraun.es