By Melissa Sheldrick and Maryanne D'Arpino
Melissa Sheldrick’s Story
"After the loss of my 8-year-old son, Andrew, to a medication error, I took it upon myself to learn everything I could about what happened and what I could do to help prevent it from happening again. There were many important lessons gleaned from my family’s tragedy, but perhaps the biggest takeaway was that this was not an individual’s fault. There were gaps in the system that allowed the error to get through and the way forward was through analysis and action. I believe a culture of learning facilitates conversation, collaboration, and the sharing of stories of successes and problems. Patients and families have an important role to play in this improvement process. Sharing Andrew’s story and reporting the errors that occurred has led to significant improvements across pharmacy systems and has brought medication safety conversations to the forefront."
Melissa’s story tells the human impact of the very sad reality that “medications sometimes cause serious harm if incorrectly stored, prescribed, dispensed, administered or if monitored insufficiently.”
In recognition that “[m]edications are the most widely utilized interventions in health care, and medication-related harm constitutes the greatest proportion of the total preventable harm due to unsafe care, let alone the economic and psychological burden imposed by such harm” the World Health Organization (WHO) has announced "Medication Safety: Medication Without Harm" as the theme for World Patient Safety Day on September 17, 2022.
"Medication harm accounts for 50% of the overall preventable harm in medical care." - World Patient Safety Day 2022
While medication-related harm is not a new patient safety issue, it has been significantly exacerbated by the ongoing COVID-19 pandemic. This is in part because factors, such as fatigue, poor environmental conditions, and staff shortages, can contribute to medication errors. During the pandemic, all sectors have struggled significantly with Health Human Resource (HHR) issues, including understaffing, exhaustion, and burnout.
This challenging situation means that care providers are facing an increased risk of contributing to unintended harm which in turn is adding to the fear, anxiety, and exhaustion they are experiencing. As wave after wave of the pandemic stretches on, we could indeed be facing a perfect storm that will impact everyone who organizes, delivers, seeks, and/or receives care, including patients, healthcare providers, and loved ones.
Making it safe-to-say
Solutions to reducing medication errors and medication-related harm are mostly the same approaches we know are needed to improve safety in all areas of healthcare. These include designing a safer healthcare system, from ward to board, by taking a proactive approach to creating safety while balancing the prevention of harm. Hand-in-hand must be the adoption of a broader definition of safety so we can better identify, evaluate and ultimately create improved patient safety that reflects the lived experience and captures the voices of everyone in Canada. This more holistic definition must address all types of harm, for all people affected, including psychological harm, dehumanization, delay in treatment, under treatment, and their underlying contributing factors such as racism, homophobia, discrimination, poor communication, and teamwork.
We also know that approaches to improving safety must include improvements in how we respond to unintended harm. Because unfortunately, despite our very best efforts to create safety and prevent harm, errors will still happen. The healthcare system is incredibly complex. And to err is human.
So, if we cannot eliminate harm, what can we do? We believe the answer lies in making it safe-to-say. We need to shift cultures and make it safe-to-say when something has, is—or could—go wrong. It is only when errors are managed appropriately, reported, responded to, and learned from that we can improve the system as a whole and support all people impacted to heal and take informed action to mitigate or prevent similar incidents from happening in the future.
A culture of blaming, shaming, and fear discourages a safe-to-say environment. We need people to feel safe and supported to speak up about concerns. When unintended harm happens we need supportive cultures that facilitate interactions and build trusting relationships; putting aside feelings of guilt, shame, and fear of legal prosecution. Feeling safe-to-say will lead to increased transparency and reporting, and learning together to build and maintain a healthier work environment for Health Human Resources and therefore for patients, Essential Care Partners, and loved ones.
As part of this culture shift to feeling safe-to-say, patients and loved ones need to be engaged as partners in safety and incident management proactively so issues can be identified through open communication in the spirit of being a true patient partners. . In the absence of this patients can feel left in the dark and re-traumatized after harm occurs
When this safe-to-say cultural shift happens, we can continue to improve and fine-tune our approach to creating safety, and learn and heal, together, when unintended harm does unfortunately occur.
As part of WPSD 2022, we hope you will join us to hear more about approaches to learning from patient safety incidents to create safer care for everyone involved, by registering to join our webinar on September 15, 2022 (12:00 – 1:00 p.m. ET).
To be notified of upcoming news and opportunities related to our work on patient safety (including the development of a new definition of safety), please subscribe to HEC’s newsletter.
To contact a member of HEC’s safety team, please email safety-securite@hec-esc.ca.
Melissa Sheldrick, Member, Patients for Patient Safety Canada and Patient and Family Advisor, Institute for Safe Medication Practices Canada
Maryanne D’Arpino, Vice-President, Programs and System Transformation, Healthcare Excellence Canada
