Alphonse Chapanis wrote a seminal paper in 1960 where he exposed the unusually high rate of medication-related errors in a 1100-bed hospital. There were seven major causes of errors in the administration of drugs:
- Omission of medicine
- Administration to the wrong patient
- Use of the wrong dosage
- Use of an unintended extra dosage
- Use by the wrong route
- Use at the wrong timing
- Administration of the wrong drug
Almost 60 years later, this issue is still critically relevant, even in developed nations, which has prodded policymakers, administrators and physicians to take the necessary corrective steps. Chapanis had identified 4 major areas:
- Written communication
- Medication procedures
- Working environment
- Training and education
In 2004 the World Health Organization (WHO) designed two major initiatives to promote clean care and surgery under the umbrella of the “Global Patient safety challenges.” On March 29, 2017, its Director General announced the launching of a third one dubbed as “Medication without Harm” in front of the national health ministers meeting in Bonn, Germany. The goal is to reduce harm related to medications by 50% over 5 years.
Initially countries will be required to target three areas of priority; high risk situations, polypharmacy and transitions of care. Afterwards the national experts will design tailored programmes to make improvements in 4 areas: health care guidelines, administration of medications, patient education and public awareness. Finally the WHO will intervene with its great human and material capacities to implement effective monitoring programs, provide technical assistance, engage with regulatory agencies and pharmaceutical companies to improve the labelling of packages and ultimately to provide the patients themselves with tools to safely manage their own medications.
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