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EVENT SUMMARY: Event summary of the roundtable event on “Preventing Medication Errors across European Hospitals to protect Patient Safety” held on 22nd March 2022 11:30-13:30 CET

The European Alliance for Access to Safe Medicines (EAASM) along with the members of the European Collaborative Action on Medication Errors and Traceability (ECAMET), organised a Parliament roundtable debate (held virtually) on “Preventing Medication Errors across European Hospitals to protect Patient Safety”, bringing together high-profile speakers from the European institutions, international organisations, and health NGOs.

The meeting represented the launch of a comprehensive White Paper on the urgent need to reduce medication errors in hospitals to prevent patient and second victim harm. The document gathers the results of a Pan-European survey on medication errors and traceability, conducted amongst 317 European hospitals, with the aim to discuss areas of improvement, and thus stimulate policymaker’s attention to intensify and implement actions to address this major patient safety issue. EAASM Executive Director Mike Isles kicked off the discussions outlining the serious consequences medication errors can bring about, not only for patients but also for the second victims, such as healthcare professionals. Medication errors can occur at any stage of the medication use process, namely during prescription, transcription, preparation, dispensing, administration and/or monitoring.

The webinar’s host MEP Tomislav Sokol (Croatia, European People’s Party), stressed that before the outbreak of the Covid-19 crisis, healthcare topics had been marginalised in public debates among the EU institutions. Healthcare was perceived as a national competence primarily, even though Member States do not have financial instruments or legal frameworks suitable for the scope, as there are currently at the European level. Differences in terms of medical performances reflected on medication errors, and are caused by different financial resources, a diverse state of health infrastructure and equipment of health personnel. Currently, thanks to the Cohesion Fund and the new budgetary program for health, it is possible to invest within healthcare systems. MEP Sokol outlined the need of data sharing and welcomed the upcoming Commission proposal on the European Health Data Space, to be adopted in May 2022.

Dr. Neelam Dhingra, Unit Head of WHO Patient Safety Flagship, pointed out that unsafe medication practices and medication errors are a leading cause of avoidable harm in healthcare systems across the world. Medication related harm represents 50% of all preventable harm in medical care, with prescribing and monitoring errors contributing to the highest sources. The cost associated with medication errors has been estimated globally at 42 billion dollars annually, not counting lost wages and productivity. It is in this context that ‘Medication Safety’ has been selected as the theme for World Patient Safety Day 2022, with the slogan ‘Medication Without Harm’.

Another valuable contribution was made by Dr. Neda Milevska-Kostova, Board Vice-Chair of the International Alliance of Patients’ Organisations (IAPO), who raised the patient voice during the meeting. Patients are often considered as end users of the healthcare service, feeling both the negative and positive aspects of healthcare, from diagnosis to follow-up. Dr. Neda called for greater interaction and engagement with patients in the continuum of care, in order to identify, reduce and prevent occurring patient harm across the healthcare systems. In 2020, IAPO established IAPO Patients for Patient Safety (P4PS) Observatory as a single-point global platform for gathering and analyzing patients’ expertise and experience that would feed into the national, regional and global policies aimed at improving safety and quality of care for patients by the patients, with the final goal to build patient-centered healthcare worldwide.

Dr. Peter Walsh, Chief Executive of Action against Medical Accidents (AvMA), put emphasis on the need to ensure absolute transparency, openness, and honesty towards patients. Moreover, the need of a solid regulatory framework has been perceived as a crucial step towards detecting, preventing and reducing the incidence of medication errors.

Mr. Ian Lindsley, Secretary of the European Biosafety Network (EBN), explained how medication errors impact a person’s psychological health. Anxiety is identified as the main mental health disorder that nurses suffered during the COVID pandemic, leading to chronic worse workplace stress. And 30% of the nurses with mental health and psychosocial disorders have been involved in medication errors or adverse events. Nurses, as second victims, have not received any professional or adequate psychological therapy.

Mr. Richard Price, Head of Policy at the European Cancer Organisation (ECCO), regretted the EU’s lack of action in this area, especially since medication errors in the oncology sector can cost patients their lives. Additionally, he shared the call to educate the workforce properly on safety issues.

Prof. Maurizio Cecconi, President of the European Society of Intensive Care Medicine (ESICM) contributed to the debate by referring to and applauding the work done by intensive care units, particularly after the outbreak of the Covid-19 pandemic. He warned about the need to increase the number of intensive care beds in Europe considering Europe’s ageing population. Hence, the need to promote a culture of risk prevention and risk mitigation.

In her closing remarks, MEP Dr. Joëlle Mélin (Identity and Democracy, France) outlined the reasons behind the delay in the prevention and treatment of medication errors and hazards across hospitals. Emphasis must be placed on training and remuneration commensurate with responsibilities; it should never be forgotten that any medication taken involves a chain of responsibilities from which no one can escape. MEP Mélin highlighted that “even with increased automation, digitalisation and robotisation of service operations, the human factor will hopefully remain a fundamental pillar of patient care”.

Institutional and cultural inadequacies have been also mentioned. The fact that only 20% of hospitals allow access to their medication error track record is not acceptable in this modern age where transparency is becoming more and more expected. This is ethically unacceptable, especially for patients.

Overall, the experts agreed on the importance of a cultural change within the medical environment. A transparent communication, greater involvement of governments in providing technological support, have been recurrent threads in the keynote speeches.

The reports reveals many positive aspects within hospitals across Europe whilst at the same pointing to areas that would benefit greatly from development in terms of funding, training and implementation of traceability systems.

The recent White Paper highlights the need to:

  1. Establishing a culture of safety
  2. Create strategies to improve communication
  3. Raise awareness and organising regular multi-disciplinary training meetings
  4. Systematically use accreditation/certification systems
  5. Introduce technological tools

In line with these recommendations, the ECAMET Alliance calls on European and national health authorities to commit to:

  • Include medication safety in the Pharmaceutical Strategy for Europe, in the EU general pharmaceutical legislation and in Europe’s Beating Cancer Plan through medication traceability systems in a healthcare setting to minimise medication errors.
  • Prioritise strategic investments in medication traceability systems in the EU4Health program to minimise medication errors.
  • Foster the development and implementation of ECDC guidelines and key indicators on medication errors in EU healthcare settings.
  • Facilitate the systematic exchange of best practices between healthcare providers both at European and national levels to reduce medication errors in healthcare setting.

If you require further information and wish to work together, do not hesitate to contact Mike Isles (mike.isles@eaasm.eu) or Laura Cigolot (laura.cigolot@eaasm.eu).

PRESS RELEASE: “The Urgent Need to Reduce Medication Errors in Hospitals to Prevent Patient and Second Victim Harm”

Brussels, 22 March 2022

Ahead of this year’s World Patient Safety Day focused on ‘Medication Safety’, the European Alliance for Access to Safe Medicines (EAASM) is organising an online Parliament roundtable debate entitled “Preventing Medication errors across European hospitals to protect patient safety: Launch of the White Paper on Medication Errors and Traceability”. The EAASM has been coordinating the European Collaborative Action on Medication Errors and Traceability (ECAMET), a patient safety initiative that brings together 21 organisations committed to the creation of regulations and guidelines on medication traceability to prevent medication errors in Europe. Several studies clearly show that medication traceability systems are the best way to address this problem.

Medication errors are the most common adverse event in hospitals, not only in terms of number, but as well in morbidity and mortality, and have significant economic and health consequences. Erroneous use of medication causes greater mortality than traffic accidents, breast cancer or the human immunodeficiency virus (HIV). In addition, healthcare staff involved in an adverse event, the ‘second victims’, may also suffer from emotional harm. This timely event aims at raising awareness about the issue by suggesting possible solutions including better medication traceability systems and improved resources in hospitals.

A comprehensive White Paper on the Urgent Need to Reduce Medication Errors in Hospitals to Prevent Patient and Second Victim Harm is about to be released, collecting the results of a pan- European survey on medication errors. In total there are 25 reports comprising 13 country reports in English, 8 languages translations, a private hospitals report, specialised oncology and ICU reports and one consolidated report. In addition, to enable a comparison between the countries and their reports an interactive dashboard has been created. This allows the use to search by question against criteria such as hospital size, type or area.

The reports reveal many positive aspects within hospitals across Europe whilst at the same pointing to areas that would benefit greatly from development in terms of funding, training and implementation of traceability systems.

The White Paper recommends requirements to reduce medication errors in hospitals and highlights the need to:

  1. Establishing a culture of safety
  2. Create strategies to improve communication
  3. Raise awareness and organising regular multi-disciplinary training meetings
  4. Systematically use accreditation/certification systems
  5. Introduce technological tools

The above topics are backed up with scientific proof of effectiveness of such measures with the survey results adding a contemporary view. The 317 completed surveys can be regarded as statistically valid and so adds to the credibility of the Call to Action.

The ECAMET Alliance calls on European and national health authorities to commit to:

  1. Include medication safety in the Pharmaceutical Strategy for Europe, in the EU general pharmaceutical legislation and in Europe’s Beating Cancer Plan through medication traceability systems in a healthcare setting to minimise medication errors.
  2. Prioritise strategic investments in medication traceability systems in the EU4Health program to minimise medication errors.
  3. Foster the development and implementation of ECDC guidelines and key indicators on medication errors in EU healthcare settings.
  4. Facilitate the systematic exchange of best practices between healthcare providers both at European and national levels to reduce medication errors in healthcare setting. If you would like further information, please do not hesitate to contact Mr. Mike Isles (mike.isles@eaasm.eu). The reports can be found on the official website www.ecamet.eu alongside the interactive dashboard.

ABOUT THE EAASM

The European Alliance for Access to Safe Medicines (EAASM) is an independent, non-profit pan- European Community Interest Company dedicated to protecting patient safety. The Alliance champions many patient safety issues to enhance medical practices, including the development of a robust and harmonised EU regulatory framework in the field of nanomedicines to protect patient safety. Other key activities include campaigning for the safer use of unlicensed/off-label medicines, better harmonisation of compounding practices, and the exclusion of falsified and substandard medicines from the supply chain. To find out more about the EAASM, please visit the website https://eaasm.eu/en-gb/ and follow @EAASMeds on Twitter.

EVENT: Preventing Medication errors across European hospitals to protect patient safety: Launch of the White Paper on Medication Errors and Traceability – 22 March 2022 – 11:30 to 13:30 CET

The European Alliance for Access to Safe Medicines (EAASM) invites you to join its Parliament roundtable debate entitled “Preventing Medication errors across European hospitals to protect patient safety: Launch of the White Paper on Medication Errors and Traceability” , taking place on 22 March 2022 from 11:30 to 13:30 CET, on the ZOOM platform.

The EAASM has been coordinating the European Collaborative Action on Medication Errors and Traceability (ECAMET) with the overall objective to markedly reduce medication errors (MEs) at European and national levels, to protect and enhance patient safety and the quality of health care.

This event will represent the occasion to officially release a comprehensive White Paper on Medication Errors and Traceability, co-written by the EAASM and the members of the ECAMET Scientific Committee, collecting the results of a pan-European survey on medication errors which acts as a catalyst to understand where improvements can be identified and acted upon, and thus stimulate innovation in the hospital setting via proven digital processes and internal dynamic behavioural changes.

Join virtually on 22nd March 2022 – Hurry up and register now! https://www.eventbrite.co.uk/e/preventing-medication-errors-to-protect-patient-safety-tickets-262415831817

Assessment of the implementation of safe medication practices in Intensive Care Units
Medication errors are a major cause of morbidity in critically ill patients. In Spain, in the SYREC study, which was carried out in 79 Intensive Care Units (ICUs), medication errors were the most frequent non-injury incident (31.2%) and the cause of 11.6% of the adverse events recorded.
Launch of the ECAMET pan-European survey to help lay the foundation for enhanced patient safety practices across Europe

Medication errors constitute the highest adverse events in hospitals, not only in terms of number, but as well in morbidity and mortality. If any type of error occurs and reaches the patient, the harm incurred is considered preventable.

After a full year of intense work, the EAASM has launched an important patient safety medication error and traceability pan-European survey. It can be completed in either English, German, Portuguese, French or Italian.

This study is being conducted by Ipsos Mori on behalf of the ECAMET Alliance, the results of which will be used to raise awareness and share best practices. This will help support advocacy for enhanced hospital traceability systems and processes which will ultimately contribute to the reduction of medication errors and thus enhance patient safety.

The survey has been sent to hospital pharmacists in a number European countries (12 in total) and we are very grateful for the support of a number of other Hospital Pharmacy Associations such as France, Italy, Portugal, Spain, the UK and Switzerland.

The final reports will include the ability to analyse the outputs from an inter and intra country perspective using an interactive e-platform.

The EAASM intends to present the survey findings in the Autumn through a high-level roundtable event, which will bring together EU and international authorities as well as a wide range of health stakeholders.

If you would like further information, please do not hesitate to contact us.

Detect Adverse Events and Medication Errors Using Technology
Technology has changed the practice of pharmacy. Many systems are now part of an ever-increasingly interfaced or integrated health care system allowing the electronic exchange of prescriptions from electronic health records (EHRs) to the pharmacy information system and bidirectional data exchange for many items, such as lab results and test information. With meaningful use of automated distribution cabinet databases, EHR efforts, electronic data exchange, and smart pump technology, the availability of data to use for addressing and preventing adverse medication events has grown. Use of these systems has allowed a data-rich environment to store and retrieve reporting. Mining data is becoming easier and can be used as a tool to identify adverse medication events or potential events.
Description of pharmacists’ reported interventions to prevent prescribing errors among in hospital inpatients: a cross sectional retrospective study
Prescribing errors (PEs) are a common cause of morbidity and mortality, both in community practice and in hospitals. Pharmacists have an essential role in minimizing and preventing PEs, thus, there is a need to document the nature of pharmacists’ interventions to prevent PEs. The purpose of this study was to describe reported interventions conducted by pharmacists to prevent or minimize PEs in a tertiary care hospital.
Optimizing smart infusion pump safety with DERS
Many medication errors can be prevented through safe medication practices; however, sometimes these errors — including those involving “smart” infusion pumps — are caused by a combination of human and technical risk factors, including fatigue, distraction, and drug library overrides, deficiencies or misuse.
A systematic review of the impact of health information technology on nurses’ time
Nursing time represents one of the highest costs for most health services. We conducted a system- atic review of the literature on the impact of health information technology on nurses’ time.
Medication Administration Errors
Medication errors have been a key target for improving safety since Bates and colleagues’ reports in the 1990s characterized the frequency of adverse drug events (ADEs) and the relationship between medication errors and ADEs in hospitalized patients. As described in related primers on medication errors and adverse drug events and on the pharmacist’s role in medication safety, the medication-use process is highly complex with many steps and risk points for error. This primer will focus on nurse-related medication administration errors.
Germany passes law to fund hospitals by 3 billion euros
germany-flag
The Federal Social Security Office of the German government has recently passed a law setting out a hospital future fund totalling 3 billion euros from the liquidity reserve of the health fund. The funds will be made available to the liquidity reserve by the federal government by the first bank working day in 2021.
Of particular relevance to the ECAMET project is the Section 19 – Eligible projects point 5, where it states “the establishment of end-to-end digital medication management to increase drug therapy safety, which provides information on all drug-related treatments across the entire treatment process in the hospital. These facilities also include robot-based actuation systems for dispensing medication”
The EAASM is very pleased with this government initiative, as the introduction of medication traceability systems greatly enhances patient safety, increases hospital efficiency whilst reducing the burden on hospital staff from manual systems which in themselves can introduce increased likelihood of errors. With 40% of nursing time spent on administrative and non health care activities1 automation can dramatically reduce manual documentation as well as the number of steps required.
Ref 1 Alianza multidisciplinar frente a los errores en la medicación del paciente hospitalizado en España como buena practica científica [Multidisciplinary alliance against errors in hospitalised patients in Spain as good scientific practice] Herranz, A, and others. Madrid: Carlos III Health Institute, 2019. V Congress on Bioethics.
ismp
One webinar (free) occuring on 21st Jan in the USA, organised by ISMP
Medication Errors: The Year in Review
Preventing medication errors is an essential component of caring for patients and must be a core mission of every pharmacy. For medication error-prevention efforts to be effective, they must be a priority
Medication Errors: The Second Victim
Medication errors are a common cause of harm to patients in acute care settings. They constitute the highest adverse events in hospitals, not only in terms of number, but as well in morbidity and mortality
Pathways for fostering patient safety across Europe
A follow up report from the collaborative discussion between policy-makers, patients, healthcare professionals and other stakeholders on the future of patient safety in Europe
Other interesting articles on medication errors, mainly in dispensing