The ultimate guide to Medication Safety Week

Julianne Chong

BPharm (Hons), MClinPharm, GCHealthServMgt (Safe&Qual), FANZCAP (Anticoag., Steward) | VTE/Anticoagulation Stewardship and QUM Pharmacist | Concord Repatriation General Hospital | julianne.chong@health.nsw.gov.au

Russell Levy

BPharm, MClinPharm, FSHP, FANZCAP (Lead&Mgmt, Med Safety), FPS | Director of Pharmacy | Royal Prince Alfred Hospital 

Garry Soo

BPharm, MClinPharm, FANZCAP (Lead&Mgmt, MedSafety) | Director of Pharmacy | Concord Repatriation General Hospital

Jocelyn Ong

BPharm, MBA | Director of Pharmacy | Canterbury Hospital

Rosemary Burke (PSM)

BPharm, Dip Ed, FSHP, FANZCAP (Lead&Mgmt, MedSafety) | Director of Pharmacy & Chief Pharmacy Information Officer | Sydney Local Health District

[Pharmacy GRIT article no: 20241398]

Medication Safety involves ensuring safe, judicious, and efficacious use of medicines to prevent patient harm.1 Suboptimal use of medicines has been observed across the healthcare continuum from the initial prescribing process, dispensing of medications, and the point of administration.2 Medication errors have led to patient harm such as increases in hospital length of stay, patient morbidity, and death.3 The global financial impact of medication errors has been estimated at $42 billion USD annually.4

The importance of Medication Safety has been promoted in the World Health Organization’s (WHO) Medication without Harm global initiative5 and has been recognised as a Joint Commission National Patient Safety Goal.6 Locally, the National Safety and Quality Health Service (NSQHS), Medication Safety Standard, mandates the need for healthcare organisations to facilitate ongoing efforts to improve Medication Safety for patients under their care.1

To build on these messages and engaging both clinicians and the broader community, we implemented a novel Medication Safety Week (MSW) health promotion across five hospitals within a Sydney metropolitan health district between 12–16 September 2022. This coincided with the WHO’s World Patient Safety Day 2022 theme: ‘Medication without Harm’ which was also celebrated by a special article series authored by the SHPA Specialty Practice Medication Safety Leadership Committee.7 The engaging promotion was also run between 25–29 September 2023 to coincide with World Pharmacist Day.

Planning and core activities

In 2022, we pulled together an enthusiastic district MSW pharmacy team comprised of 13 pharmacists and pharmacy technicians with representation across five hospital sites. An implementation plan was developed and progressed over three months with fortnightly to weekly meetings facilitated virtually via Microsoft (MS) Teams (Microsoft Corporation, Redmond, WA, USA). We also successfully obtained $500 AUD of district funding to support the project.

Figure 1. Medication Safety Week 2022 promotional flyer

A MS Excel spreadsheet was shared electronically on Teams to allow members to collaboratively organise ideas, plan for activities, allocate budget, and to prepare a communication and promotion strategy. There were several core activities undertaken for MSW 2022 (see Figure 1) aimed at increasing engagement with Medication Safety messages and incentivising participation. These included education seminars, promotional stalls, and daily quizzes.

Face-to-face and virtual education seminars for pharmacists, nurses, and medical officers:

  • These seminars were delivered from a different hospital site each day between 2pm and 4pm and simulcast using Zoom (Zoom Video Communications Inc., San Jose, CA, USA) videoconferencing to virtual participants.
  • Senior nursing and medical staff were approached to present sessions, alongside those presented by pharmacy staff.

Daily topics were arranged by theme including insulin, delirium, opioids, sepsis, falls, anticoagulants, and electronic prescribing.

Promotional stalls at every hospital:

  • Materials moved each day to a different hospital site to prevent unnecessary wastage and reduce organisational burden on individual hospitals. One of the stalls can be seen in Figure 2.
  • Activities at the stalls included a Medication Safety ‘spin the wheel’ quiz for staff and a separate quiz for consumers.

Daily online Medication Safety quizzes:

  • Quizzes were designed using MS Forms and emailed across facilities to medical, nursing, and pharmacy staff daily.

A $25 gift card prize could be won for attendance at an education session, visiting a stall, or completing an online quiz.

Figure 2. 2022 promotion stall

L to R from Concord Repatriation General Hospital:

Betty Wong (Ph), Trina Ahmad (Ph), Katherine Borg (Ph), Francis Pang (Ph), Julianne Chong (Ph), Chin Yen Yeo (Ph), Nina Phan (Ph), James Pan (Ph), Jessica Iannacito (Ph), Edward Chang (MO).

Ph = pharmacist; MO = medical officer

In addition, we incentivised participation on training modules and held education sessions for consumers. These incentives are described below. 

Health Education and Training Institute (HETI) Medication Safety module promotion

  • Completion of Medication Safety HETI modules were incentivised by the chance to win a $100 gift card.
  • The module topics were: Safe Use of High-Risk Medicines; Safe Use of Hydromorphone; Safe Use of Anticoagulants; Safe Use of Opioids; Safe Use of Insulin: Challenge; Safe Use of Benzodiazepines in the Older Person; and Vaccine Storage and Cold Chain Management.

Multi-lingual consumer education sessions

  • Local community organisations identified by the district Diversity Hub were approached to host a Medication Safety education session on falls delivered by pharmacists in their native language.
  • Education sessions were promoted by local community organisations.

Promotion of the MSW event included advertising on the district intranet bulletin board, an email announcement from the Chief Executive of the Sydney Local Health District, daily emails from the MSW team throughout the week, and the distribution of flyers designed by the district communications team across facilities.

Growing the impact

Engagement with the 2022 MSW event was considerable:

  • 262 staff attended our Medication Safety seminars
  • 421 staff and consumers completed a Medication Safety quiz
  • 240 staff and consumers visited our Medication Safety stalls
  • 98 consumers attended our multi-lingual community presentations in Cantonese, Mandarin, and Korean.
  • 357 HETI modules were completed by 137 staff.

The successful 2022 framework was then expanded in 2023. A team of 40 pharmacists and technicians commenced preparations in April 2023 and district funding for 2023 MSW was increased to $1000. This facilitated adding additional promotional strategies including the implementation of an electronic banner for MSW on our district intranet page and, to expand promotion to other hospital districts, a post on the SHPA Medication Safety forum and email distribution through pharmacy schools at the University of Sydney, the University of NSW, and University of Technology Sydney.

Figure 3. Medication Safety Week 2023 promotional flyer

Building on the previous years’ campaign, additional enhancements were added in 2023 and outlined here (see Figure 3).

Safest ward imprest competition:

  • The competition was conducted by ward pharmacists using a tool designed on MS Forms which could be used in the future for quality ward walkarounds
  • The judging criteria included compliance with high-risk medicines storage and fridge monitoring requirements and general tidiness
  • The winning ward at each facility was presented with a $50 food hamper.

Focus on health care professional wellbeing:

  • ‘Positivity prescriptions’ were handed out at promotional stalls (comprised of a chocolate frog and positive message and wrapped up in a labelled prescription box). See Figure 4 for an example.

Positive messages included:

“If you see someone without a smile, give 'em yours!” — Dolly Parton

“You are your best thing”— Toni Morrison, Beloved

“Anything is possible with sunshine and a little pink” — Lilly Pulitzer

  • Education sessions were provided by our district wellbeing program (MDOK) lead and by the Pharmacists’ Support Service.

Figure 4. Positivity prescription

Consumer workshop on Medication Safety:

  • A pharmacist-facilitated consumer workshop was promoted among the local community through our facility volunteer groups and at the local library.
  • Activities included a MS PowerPoint presentation, medication list making session, Medication Safety tips bingo, and a webster packing competition.
  • Consumers had the opportunity to win a $25 gift card for attending the workshop.

Additional activities for our promotional stall:

  • A Parkinson’s Disease medicines selection (name to box/bottle) accuracy test
  • A ‘pick the gingerbread house’ decorated with medicines (rather than lollies). Picture use kindly provided by the Poison Information Centre NSW.

In 2023:

  • 184 staff attended our Medication Safety seminars
  • 472 staff and consumers completed a Medication Safety quiz
  • 201 staff and consumers visited our Medication Safety stalls
  • 117 consumers attended our community presentations in Cantonese, Mandarin, and Korean
  • 86 HETI modules were completed by 56 staff
  • 8 consumers attended our workshop.

Despite increases in consumer attendance and Medication Safety quiz completion between 2022 and 2023, there were reductions in staff seminar attendance, stall visits, and HETI module completion. It is possible that with smaller incentives ($10 coffee vouchers instead of $25 gift card for activity attendance and $50 gift cards instead of $100 for module completion) may have affected participation rates. Also, with a larger variety of activities and more opportunities to participate in MSW, such as the ward imprest competition, less staff may have participated in individual activities. Individual MSW activities may have been less prominent in our promotion of MSW due to the greater volume of events.

Feedback from our consumer workshop, which was facilitated by six pharmacists, was overwhelmingly positive:

“All the presenters were very good and gave great presentations that were easy to understand and very interesting. Learnt a few things I was unaware could be harmful if instructions aren’t followed.”

“I would attend any updated presentations as this one was very good.”

Despite the uncertain effectiveness of healthcare provider education on reducing medication error rates in hospital,8 promotion of Medication Safety, particularly for high-risk medicines, remains a strategy healthcare facilities should implement as an adjunct to other initiatives to meet NSQHS Standards.1 Our successful implementation of a district wide MSW promotion with high impact was one step towards minimising avoidable patient harm from medication. Incentivising staff to dedicate time to complete Medication Safety modules and to attend education sessions was particularly effective. We believe our framework for MSW could be used at other healthcare facilities as an ongoing annual initiative to educate key audiences on Medication Safety with the flexibility to focus on different areas of need annually.  

Acknowledgements

The authors would like to acknowledge the contributions of Alexander McNamara, Carolyn Woods, Sabrina Wu, Seniha Kasif, Sohileh Aran, Omar Mubaslat, Hannah Turton, Rebekah Lee, Hari Kim, Vicki Zhang, Susanna Yang, Seung (Sarah) An, Linda Do, Trina Ahmad, Katherine Borg, Bruce Wu, and Grace Moujalli, as well as the pharmacy departments of Concord Repatriation General Hospital, Royal Prince Alfred Hospital, Canterbury Hospital, Balmain Hospital, and the Concord Centre for Mental Health.

References 

  1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Medication Safety Standard. Sydney: ACSQHC; 2023. Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-standard. Accessed 22 December 2023.
  2. Manias E, Kusljic S, Wu A. Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Ther Adv Drug Saf 2020; 11: 2042098620968309.
  3. Sodré Alves BMC, de Andrade TNG, Cerqueira Santos S, Goes AS, Santos ADS, Lyra Júnior DP, et al. Harm prevalence due to medication errors involving high-alert medications: a systematic review. J Patient Saf 2021; 17: e1–e9.
  4. World Health Organization (WHO). WHO global patient safety challenge. Geneva: WHO; 2017. Available from https://iris.who.int/bitstream/handle/10665/255263/WHO-HIS-SDS-2017.6-eng.id=23E3E58293025B546A38236B7882AFC7?sequence=1. Accessed 22 December 2023.
  5. WHO. Medication without harm. Geneva: WHO; 2023. Available from https://www.who.int/initiatives/medication-without-harm. Accessed 22 December 2023.
  6. The Joint Commission. National patient safety goals®: effective July 2023 for the hospital program. Oakbrook Terrace, IL: The Joint Commission; 2023. Available from:  https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jul2023.pdf. Accessed 22 December 2023.
  7. Medication Safety Leadership Committee. World Patient Safety Day series 2022. Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2022. Available from https://www.adpha.au/publications-resources/medication-safety/world-patient-safety-day-series. Accessed 29 February 2024.  
  8. Ciapponi A, Fernandez Nievas SE, Seijo M, Rodríguez MB, Vietto V, García-Perdomo HA, et al. Reducing medication errors for adults in hospital settings. Cochrane Database Syst Rev 2021; 2021(11): CD009985.