This issue of the journal reminds us that nearly all patients admitted to hospital will experience at least one error or medication-related problem during their hospital stay,1 with many patients likely to experience multiple errors. These figures were compiled from multiple studies, where each study examined one piece of the puzzle. This too reminds us of further challenges in assessing and improving medication safety across the whole health system. No comprehensive audits of medication safety errors exist, where medication errors across all aspects of hospital care are measured. All studies to date have examined medication safety from the perspective of single health practitioner practice, such as prescribing, dispensing, or administration errors, rather than any of those types of errors across the whole patient journey. This is despite repeated calls for a systems approach to improving medication safety.

In addressing systems factors, much work has already been undertaken by the US Agency for Healthcare Research and Quality synthesizing the literature to determine what works to improve medication safety.2 Recommended strategies for implementation include clinical pharmacy services as there is moderate to high evidence showing these services reduce adverse medication events, particularly in the intensive care unit.2 Computerized prescription ordering systems with clinical decision support systems are also recommended as there is moderate evidence showing they can reduce prescribing errors, although the extent to which they reduce clinical errors is unclear and they do require a planned implementation strategy to ensure they are integrated into health practice work flows.2 Medication reconciliation services are also recommended, and keeping with systems theory, the evidence is strongest where these services are integrated with other activity.2 Finally, although the evidence for 'do-not-use' lists for abbreviations is low, it is a recommended strategy as it is considered low cost and easy to implement.2

The US Agency for Healthcare Research and Quality also identified priority areas for research including postdischarge care transitions, human factors engineering, and ergonomics in the design of health care practices and measures to encourage a culture of patient engagement in patient safety practices.2

The need for patients or their carers to be active participants in the systems approach to improving medication safety has become urgent, as more and more people are living with multiple chronic illness, are taking multiple medicines and are being treated by multiple providers; all of which increase the risk of error.3 When considering the patient role in medication safety, a survey of 100 patients found over 80% thought they would check with a health professional if they had been given the wrong medicine or not given the required medicine; however, only 30% had looked at their medication chart while in hospital.4 This highlights a gap in practice, as many patients would not be able to alert their health professionals to potential errors in their care if they are not actively involved in checking charts or advised of medication changes while in hospital.5

Active patient involvement in interventions will also form part of the solution. The article in this journal synthesizing the evidence for reducing multiple antipsychotic use shows the evidence is stronger for direct trials involving patients than for trials involving health practitioner education alone.6 The article on vaccine safety in this issue also highlights the importance of patient engagement; with the vaccine advice line, an important source of information about vaccine errors, now receiving reports from parents, as well as childcare providers.7

Consumer reporting of adverse medication events has been shown to identify potential adverse events not detected by health professionals8 and to lead to earlier detection of events.9 In a similar manner, consumer involvement in medication safety initiatives, both in detection and prevention, is likely to provide significant opportunities to provide safer care; however, consumer engagement has been limited in the research undertaken to date.2

This issue of the journal is a timely reminder that our work is not yet done; significant challenges in improving medication safety remain, particularly with regard to implementing systems solutions and providing an evidence base for consumer engagement. Focusing on the whole patient journey may provide us with an opportunity to reconsider the systems approach as we strive to reduce errors in care, enabling us to identify opportunities for patient participation in medication safety initiatives and supporting efforts to improve continuity of care across the patient journey.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

REFERENCES