WHO World Patient Safety Day 2022

The World Health Organization (WHO) World Patient Safety Day takes place on 17 September every year. The theme for 2022 is Medication Safety. The Commission continues to support WHO in their efforts to increase safe use of medicines.

Overview

The theme for World Patient Safety Day 2022 is Medication Safety, building on the WHO Global Patient Safety Challenge - Medication without Harm. Health services are encouraged to take action and prioritise medication safety across the WHO's three flagship areas:

  1. Monitoring polypharmacy and responding to inappropriate polypharmacy
  2. Reducing harm from high-risk medicines
  3. Improving medication safety at transitions of care

Patients, with the support of their healthcare providers, are also encouraged to better understand their medicines to improve their safe and quality use of medicines. 

WHO Global Patient Safety Challenge

The Commission was engaged by the Australian Government Department of Health to develop Australia’s response to the third WHO Global Patient Safety Challenge – Medication without harm. This response presented information on medication safety programs and initiatives in Australia in 2020, and recommended priority actions to achieve goals of the Challenge.


Initiatives around Australia

To mark World Patient Safety Day 2022, the Commission invited health services around Australia to showcase their initiatives in reducing medication-related harm, across one or more of the WHO flagship areas.

A range of exemplar projects, highlighting various quality improvement achievements in medication safety, were received.

Polypharmacy

Key message

Monitoring polypharmacy and responding to inappropriate polypharmacy

Polypharmacy is the concurrent use of multiple medicines, often defined as five or more medicines. This includes over-the-counter, prescription and traditional/complementary medicines used by a patient. Inappropriate polypharmacy is the prescribing of multiple medicines inappropriately, or where the intended benefit of the medicine is not realised.

Regular monitoring and review of medicines, along with individual patient factors, is required to ensure appropriate polypharmacy, and reduce inappropriate polypharmacy. 

Commission resources

Safer naming and labelling of medicines

The Commission support clinicians and patients to better identify medicines with a number of resources to improve the safety and consistency of medicines naming, labelling and packaging.

National Standard for Labelling Dispensed Medicines
2021
Publication, report or update

Monitoring polypharmacy

  • The Fourth Australian Atlas of Healthcare Variation review of medicines use in older people: 6.1 Polypharmacy, 75 years and over highlights rates of polypharmacy in this population group.

Know Check Ask

WHO Medication Safety Webinar series

Medication Safety in Polypharmacy 

Know Check Ask 

  • Everyone has a role to play in medication safety - 'Know-Check-Ask' campaign posters are useful resources to engage clinicians and encourage patients to think about medication safety and be actively involved in the safe and quality use of medicines. 
  • Engaging patients through shared decision-making using tools such as the 5 Moments for Medication Safety.

Key message

Monitoring polypharmacy and responding to inappropriate polypharmacy

Polypharmacy is the concurrent use of multiple medicines, often defined as five or more medicines. This includes over-the-counter, prescription and traditional/complementary medicines used by a patient. Inappropriate polypharmacy is the prescribing of multiple medicines inappropriately, or where the intended benefit of the medicine is not realised.

Regular monitoring and review of medicines, along with individual patient factors, is required to ensure appropriate polypharmacy, and reduce inappropriate polypharmacy. 

Commission resources

Safer naming and labelling of medicines

The Commission support clinicians and patients to better identify medicines with a number of resources to improve the safety and consistency of medicines naming, labelling and packaging.

National Standard for Labelling Dispensed Medicines
2021
Publication, report or update

Monitoring polypharmacy

  • The Fourth Australian Atlas of Healthcare Variation review of medicines use in older people: 6.1 Polypharmacy, 75 years and over highlights rates of polypharmacy in this population group.

Know Check Ask

WHO Medication Safety Webinar series

Medication Safety in Polypharmacy 

Know Check Ask 

  • Everyone has a role to play in medication safety - 'Know-Check-Ask' campaign posters are useful resources to engage clinicians and encourage patients to think about medication safety and be actively involved in the safe and quality use of medicines. 
  • Engaging patients through shared decision-making using tools such as the 5 Moments for Medication Safety.

High-risk medicines

Key message

Reducing harm from high-risk medicines

High-risk medicines if misused, or used in error can cause significant patient harm or death. The high-risk medicines of focus in Australia are insulin, opioid analgesics, anticoagulants and antipsychotics. The APINCHS classification can assist clinicians to identify the other groups of high-risk medicines of concern.

High-risk medicines warrant special mechanisms and risk-reduction strategies to identify and intercept medication errors before they result in harm to the patient.

Action 4.15 of the National Safety and Quality Health Service (NSQHS) Standards outlines these strategies.

Commission resources

Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

A new national standard with accompanying resources to support the appropriate use and review of opioid analgesics for the management of acute pain to optimise patient outcomes and reduce the potential for opioid-related harm in Australia. An opioids campaign communication kit has also been developed to support implementation of the standard.


High-risk medicine education 

National e-learning high-risk medicine courses to improve the safe use of high-risk medicines in hospitals. The current topics available include:

  • An Introduction to High Risk Medicines
  • Insulin
  • Anticoagulants
  • Clozapine
  • Opioids.

Other Clinical Care Standards

Key message

Reducing harm from high-risk medicines

High-risk medicines if misused, or used in error can cause significant patient harm or death. The high-risk medicines of focus in Australia are insulin, opioid analgesics, anticoagulants and antipsychotics. The APINCHS classification can assist clinicians to identify the other groups of high-risk medicines of concern.

High-risk medicines warrant special mechanisms and risk-reduction strategies to identify and intercept medication errors before they result in harm to the patient.

Action 4.15 of the National Safety and Quality Health Service (NSQHS) Standards outlines these strategies.

Commission resources

Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

A new national standard with accompanying resources to support the appropriate use and review of opioid analgesics for the management of acute pain to optimise patient outcomes and reduce the potential for opioid-related harm in Australia. An opioids campaign communication kit has also been developed to support implementation of the standard.


High-risk medicine education 

National e-learning high-risk medicine courses to improve the safe use of high-risk medicines in hospitals. The current topics available include:

  • An Introduction to High Risk Medicines
  • Insulin
  • Anticoagulants
  • Clozapine
  • Opioids.

Other Clinical Care Standards

Transitions of care

Key message

Improving medication safety at transitions of care

Transitions of care occur when all or part of a patient’s healthcare is transferred between healthcare locations, settings or providers. Medication errors can arise at these transitions, with common discrepancies including: omission of medication (most common), wrong dose, drug-drug interaction, contraindication or duplication of therapy. 

At each transition of care, medicines information should be available, current and communicated to both the patient and their healthcare providers. 

Action 4.05 to 4.12 of the NSQHS Standards outlines strategies for medication review, reconciliation and ensuring continuity of care.

Commission resources

Quality Use of Medicines

The Commission undertakes projects and programs to support the safe and quality use of medicines.

The Commission was recently engaged by the Australian Government Department of Health to review and update the following national Quality Use of Medicines (QUM) publications. These are anticipated to become available in the coming months.

  • Guiding principles for medication management in residential aged care facilities
  • Guiding principles for medication management in the community
  • Guiding principles to achieve continuity in medication management

Medication reconciliation and continuity of care

Electronic medication management

The Commission has developed a number of resources to support electronic medication management (EMM) and e-health safety.

Key message

Improving medication safety at transitions of care

Transitions of care occur when all or part of a patient’s healthcare is transferred between healthcare locations, settings or providers. Medication errors can arise at these transitions, with common discrepancies including: omission of medication (most common), wrong dose, drug-drug interaction, contraindication or duplication of therapy. 

At each transition of care, medicines information should be available, current and communicated to both the patient and their healthcare providers. 

Action 4.05 to 4.12 of the NSQHS Standards outlines strategies for medication review, reconciliation and ensuring continuity of care.

Commission resources

Quality Use of Medicines

The Commission undertakes projects and programs to support the safe and quality use of medicines.

The Commission was recently engaged by the Australian Government Department of Health to review and update the following national Quality Use of Medicines (QUM) publications. These are anticipated to become available in the coming months.

  • Guiding principles for medication management in residential aged care facilities
  • Guiding principles for medication management in the community
  • Guiding principles to achieve continuity in medication management

Medication reconciliation and continuity of care

Electronic medication management

The Commission has developed a number of resources to support electronic medication management (EMM) and e-health safety.