60 min · sample content, pending qualified review
1. The medication process and the safety system
Medication care is one of the most common interventions in healthcare — and one of the most common sources of preventable harm. The World Health Organization estimates that unsafe medication practices and errors cost health systems billions of dollars every year, and in 2017 launched the Global Patient Safety Challenge “Medication Without Harm” with the aim of reducing severe, avoidable medication-related harm. This module explains why medication safety is treated as a system property rather than only an individual skill.
Learning objectives
- Name and describe the stages of the medication process
- Explain why most medication errors are system failures with multiple contributing factors
- Describe the purpose of a unit-level medication plan
The stages of the process
The medication process is a connected chain: (1) assessing the need for medication together with the patient; (2) prescribing and planning; (3) supply, dispensing and storage; (4) preparation; (5) administration; (6) monitoring effectiveness and adverse effects; (7) documentation and information transfer; and (8) patient education and shared decision-making. Some models also add review and discontinuation (deprescribing) as an explicit stage.
Every stage has a named, accountable professional. A prescriber decides on treatment; a pharmacist verifies and dispenses; a nurse or other authorised professional prepares, administers and monitors. Because each stage depends on the information produced by the previous one, a weakness anywhere can travel down the chain. Studies consistently show that a large share of errors originate at prescribing and transcription but are only intercepted — or not — at administration.
Systems thinking
James Reason’s “Swiss cheese” model describes safety barriers as slices with holes: interruptions, look-alike packaging, unclear orders, fatigue, staffing gaps. Harm happens when the holes line up. The lesson is that blaming the last person in the chain rarely prevents the next error; improving barriers — standardised processes, clear labelling, double checks for high-risk steps, a reporting culture — does.
Human factors matter. Interruptions during preparation are strongly associated with errors; many organisations use “do not disturb” zones or tabards during medication rounds. Memory is unreliable under pressure, so checklists and structured communication are deliberate safety tools, not bureaucracy.
The unit medication plan
Finnish guidance (Safe Pharmacotherapy, 2021) requires every unit that provides medication care to have a written medication plan describing: the content and scope of medication care, roles and responsibilities, how competence is ensured and verified, prescribing and dispensing arrangements, storage, information transfer, monitoring and how errors are handled. The same idea fits well with Malaysian and Indonesian quality and accreditation expectations: written, known and regularly updated local procedures.
As a professional you should know where your unit’s plan is, what it allows you to do and who to ask when it is silent.
Key points
- Medication care is a chain; know the stage you are responsible for and its inputs and outputs.
- Most errors have several system causes — strengthen barriers rather than seek blame.
- Your unit’s written medication plan defines your role locally.
Practice case — reflect
During an evening round a nurse is interrupted three times while preparing medicines for six patients. Two products in similar boxes stand side by side. Identify at least three barriers that could reduce the risk of a wrong-medicine error in this situation.
Sources and further reading
- Medication Without Harm — Global Patient Safety Challenge — World Health Organization
- Patient Safety Curriculum Guide: Multi-professional Edition — World Health Organization (2011)
- Turvallinen lääkehoito — Safe Pharmacotherapy guide — Ministry of Social Affairs and Health, Finland (2021)