The IMSN welcomes the new World Health Organisation (WHO) publication concerning medication error reporting and learning systems just been published:
“Reporting and learning systems for medication errors: the role of pharmacovigilance centres” Access to the WHO Library
This publication has been developed as part of the “Monitoring Medicines” project funded by the European Union and was completed in 2012 with the valuable contribution of several members of the IMSN to its preparation and critical review.
This publication is intended to strengthen the capacity of national pharmacovigilance centres (PVCs) to identify, analyse and issue guidance to prevent or minimize medication errors (MEs) that harm patients. In the majority of countries there is no patient safety organisation. There are national PVC’s in most countries and these centres can do more to increase awareness, promote safer practice and minimise harms arising from medication errors, including these involving medical devices.
In those countries where there are patient safety organisations it is intended to stimulate cooperation between national PVCs and patient safety organizations (PSOs) to work together in order to minimize preventable harms from medicines.
The publication includes background and technical guidance on the principles and methods of ME incident reporting and learning. It outlines RCA and FMEA methods and provides NPSA examples of solutions designed to minimise the risk of harms from medication errors. This information is intended to assist PVCs and PSOs to begin using the same philosophy, terminology and processes when undertaking this work.