Medication Without Harm: WHO's Third Global Patient Safety Challenge

1680 www.thelancet.com Vol 389 April 29, 2017 In 1960, Alphonse Chapanis, turned his attention from engineering to health care. In a study of medicationrelated errors in a 1100-bed hospital, he and his colleague identified seven sources of such errors potentially leading to harm to a patient: medicine omitted, or given to the wrong patient, at the wrong dose, as an unintended extra dose, by the wrong route, at the wrong time, or as the wrong drug entirely. Almost 60 years later, these same types of errors still happen worldwide. Later that year in a follow-up policy paper, Chapanis identified four areas of recommendations that could prevent harm and remain relevant today: written communication, medication procedures, the working environment, training, and education. Indeed, it is difficult to avoid the conclusion that had the recommendations from this revelatory patient safety research been assiduously followed over the past five decades, hundreds of thousands fewer patients would have been killed or seriously harmed by the medicines intended to make them well. Beginning in 2004, WHO, working in partnership with the then World Alliance for Patient Safety, initiated two Global Patient Safety Challenges, Clean Care is Safer Care and Safe Surgery Saves Lives. These challenges mobilised worldwide commitment and action to reduce health-care-associated infections and risk associated with surgery, respectively. At the second Global Summit of Health Ministers on Patient Safety in Bonn, Germany, on March 29, 2017, the Director-General of WHO announced that the Third Global Patient Safety Challenge, Medication Without Harm, would address medication safety. The previous challenges secured strong and early commitment from health ministers, professional bodies, regulators, health leaders, civil society, and health-care practitioners. The action required to deliver the goals of each was broadly similar: an evidence-based analysis of the key problems and solutions; an invitation to WHO member states and other relevant parties to pledge, or sign-up, to address the aims of the challenge; high-profile actions to generate passion and enthusiasm; facilitation Medication Without Harm: WHO’s Third Global Patient Safety Challenge *Neil R Poulter, Daniel T Lackland School of Public Health, Imperial College London, London W12 7RH, UK (NRP); and Department of Neurology, Medical University of South Carolina, Charleston, SC, USA (DTL) [email protected]