WHO Global Patient Safety Challenge- Medication without harm series 'Medication error reporting and learning, and pharmacovigilance systems”

13 April, 2022

I enjoyed this webinar. Professor Sir Liam Donaldson is the WHO envoy for patient safety and Sir Lam wrote to Dr Margaret Chan the then DG of the WHO in 2009 recommending patient access to records to the WHO EC directive on digital care. Patient access to records was included in the WHO 2021 to 2030 Patient Safety project which was ratified at the 74th WHJA in May 2021 at Geneva.

Here is my summary of the webinar on the medication without harm webinar held on April 12th 2022 Geneva 13.00 (The WHO Global Patient safety Challenge– Medication without harm series 'Medication error reporting and learning, and pharmacovigilance systems')

Medication Safety Webinar series: WHO Global Patient Safety Challenge (https://www.who.int/news-room/events/detail/2022/02/08/default-calendar/...)

50% of all harm in patient care is harm caused by meditation.

Patients are educated to “know your medication”, check the dose and time of your medication” and “ask your healthcare professional”.

Materials are in English, French, Russian and Spanish.

There are two sets of information available for the WHO pharmacovigilance


- Information from information systems set up to collect errors

- Adapting data used for routine care

This webinar is about the WHO technical report and guidance about information systems set up to manage patient safety incident reporting and learning systems.

System for managing patient safety incidents reportring and learning follows a pattern:

- Creating and collecting incident reports

- Assessing the incident reports

- Investigating the incident reports

- Seeking insight into the system in which the incident took place

- Creating an action plan

- Designing future method to present similar incidents.

There are barriers to the full implementation of incident report systems:

- Large volumes of data

- Cultural resistance

- Limited investigative capacity

There are Patient Safety Reporting Systems (PSRS’s) and Pharmacovigilance (PV)

WHO programme for international drug monitoring started in 1961 following the incidents attached to children who had been exposed to thalidomide before birth.

National regulatory authorities feed information from service providers and manufactories to national pharmacovigilance centres. These are increasingly fed to the WHO global database of case reports hosted in Vigibase in Upsala, Sweden. Vigibase contains over 30 million reports. Reporting to Vigibase have increased since 2012 at which time many countries instigated legislation requiring reporting safety incidents.

There is a medical dictionary of terms for Regulatory Activities (MedRA) which contains international standards for the most frequently reported medication errors for universal use. From these come standardised MedRA Queries SMGs (https://www.meddra.org/)

The American and Canadaian International Medication Safety Networks (ISMPs) voluntary not for profit non regulatory organizations that record and analyse

1) Medication errors

2) Vaccine errors

3) Consumer errors

The presentation from Botswana described how none of the previously mentioned syatems had been in place but were being implemented. Finally a patient presented the experience of multiple safety incidents on a relative.

HIFA Profile: Richard Fitton is a retired family doctor - GP. Professional interests: Health literacy, patient partnership of trust and implementation of healthcare with professionals, family and public involvement in the prevention of modern lifestyle diseases, patients using access to professional records to overcome confidentiality barriers to care, patients as part of the policing of the use of their patient data.

Email address: richardpeterfitton7 AT gmail.com