NATIONAL ACTION PLAN ON MEDICATON SAFETY

FOR SRI LANKA

Prepared by
Directorate of Healthcare Quality and Safety
Ministry of Health
Sri Lanka

December 2021

This document will be subjected to revision as needed during implementation.

2
National Action Plan on Medication Safety for Sri Lanka
© Copyright Ministry of Health, Sri Lanka, 2021
First Edition: 2021 September

Edited By:
Dr. G.S.K. Dharmaratne,
Former Director, Healthcare Quality and Safety,
Ministry of Health, Sri Lanka

Dr. Dewanee Ranaweera,

Director (Covering Up), Directorate of Healthcare Quality and Safety,
Ministry of Health, Sri Lanka.

Prof. PriyadharshaniGalappatthy
Department of Pharmacology,University of Colombo

Dr. Priyantha Liyanage,

Consultant Community Physician,Directorate of Healthcare Quality and Safety,
Ministry of Health, Sri Lanka.

Dr.D.G.A.S.Prabha,
Medical Officer,Directorate of Healthcare Quality and Safety,
Ministry of Health, Sri Lanka.

ISBN ………………………………………..
Published by
Directorate of Healthcare Quality and Safety

All rights reserved.

Printed by
Department of Government Printing
The cover page artwork is by medical student Ms Nimsis Jayaweera, selected as one of the
10 best posters at the student poster competition held for the inaugural World Smart
Medication Day, 2021.
 Directorate of Healthcare Quality and Safety
Premises of Castle Street Hospital for Women, Castle Street, Colombo 08.
Telephone: 011-2678598, Fax: 011-2698602
Email:dhqualitys@gmail.com / dirhqs@health.gov.lk
Web: www.quality.health.gov.lk
MESSAGE FROM THE SECRETARY, MINISTRY OF HEALTH

With the growing reliance on medication therapy as the primary intervention for most
illnesses, patients receiving medication interventions are exposed to potential harm as well as
benefits. Medication-related errors are a significant cause of morbidity and mortality around
the world. It can occur in all settings and may or may not cause an adverse drug event (ADE).
Medications with complex dosing regimens and those given in specialty areas (e.g., intensive
care units, emergency departments, and diagnostic and interventional areas) are associated
with increased risk of ADEs.

Lack of appropriate policies, procedures, and protocols can have a greater impact on
medication safety. Therefore, developing a national action plan on medication safety is a
timely intervention and I would like to convey my sincere gratitude to the team involved in
developing this document. I hope it will help to provide better outcomes in our healthcare
services.

Dr. S.H. Munasinghe

Secretary
Ministry of Health
MESSAGE FROM ADITIONAL SECRETARY (MEDICAL SERVICES)

Throughout the history of mankind, medicines of various forms and medical interventions,
have played a crucial role in treating and preventing diseases. Further,their multitude of
physical, chemical, and biological characteristics, pharmaceutical and therapeutic properties
also have been developed into their current status, thanks to the efforts and commitment of
large number of professionals representing different professions involving technologies,
experiments, heavy financial and other resource investments.
It is also a well-known fact that medicines similar to any other natural or manmade substance
used by humans also can produce hazards, errors or may lead into adverse or undesirable
effects or outcomes.
Therefore, it is a responsibility of a sound health system to establish and adopt a scientific
and practical medication safety mechanism to ensure a more safer health service at each level
of care.
In this context Directorate of Health Care, Quality and Safety has taken a pragmatic approach
to formulate a national action plan on medication safety, based on four major strands, system
and practices, medicines, healthcare professionals and patients in accordance with
international standards.
As Additional Secretary Medical Services, I do highly appreciate this endeavor, with the
assurance of my fullest support for its successful implementation.

Dr.A.K.S. De Alwis
Additional Secretary (Medical Services)
Ministry of Health
MESSAGE FROM THE DIRECTOR GENERAL OF HEALTH SERVICES

Sri Lanka has made remarkable progress in improving the health status of our population. Since
1920s, the country has made dramatic strides on key outcome indicators such as life expectancy
and maternal & child mortality, following delivery of productive and efficient healthcare free of
charge.

Considering the further improvement of quality and safety of healthcare, prevention of

medication errors is a priority area, as currently it is one of the leading causes of patient harm
globally. Although most are preventable errors they occur and recur at an alarming rate.
Inadequacy of awareness among both healthcare providers and patients regarding medication
safety and also unavailability of accurate statistics give a major contribution towards the
occurrence of more and more drug related issues in patient management.

It is a timely initiative to develop a National Action Plan on Medication Safety for Sri Lanka to
minimise the medication related errors in both public and privet sector. Therefore, I appreciate
the efforts of the team of Directorate of Healthcare Quality and Safety and all the contributors
for developing this national action plan on medication safety for Sri Lanka.

Dr.AselaGunawardana

Director General of Health Services

Ministry of Health
MESSAGE FROM THE DEPUTY DIRECTOR GENERAL MEDICAL SERVICES I

Sri Lanka holds a unique position in South Asia as one of the first developing nations to provide
universal health. The Health Ministry and the Provincial Health Services provide a wide range of
promotive, preventive, curative and rehabilitative health care. With all these efforts despite being
a lower middle-income country, Sri Lanka has achieved commendable health indicators.

Having achieved better outcomes in relation to maternal and child health and communicable
diseases, Ministry of Health has now focused to improve the quality and safety of care provided by
health sector, which will lead to further improvements in health indicators as well as the
satisfaction of the patents. Prevention of medication errors and establishment of medication
safety, play a major role in that purpose, since considering the unacceptably high number of
deaths and disabilities associated with it. A National action Plan on Medication Safety is therefore
a timely requirement for Sri Lanka in achieving future targets.

My sincere appreciation goes to the Directorate of Healthcare Quality and Safety, Professor
PriyadarshaniGalappatthy and all the other stakeholders for their contribution in development of
this national action plan.

Dr. Lal Panapitiya

Deputy Director General Medical Services I

Ministry of Health
Message from Senior Professor of Pharmacology, University of Colombo

Medication errors have become a global concern and a large number of preventable deaths
and serious harm occur globally due to medication errors. World Health organization(WHO)
has given leadership in preventing serious patient harm due to medication errors by
launching ‘Medication without harm’ as the 3rd global patient safety challenge in 2017. To
achieve this ambitious, yet achievable objective, each country was requested to develop
individualized national action plans to ensure medication safety.

The WHO expert working group on medication without harm identified four main strands to
focus during development of national action plans, the systems and practices, healthcare
persons, medicines and patients in each country with 3 further flagship areas, medication
safety in poly pharmacy, high risk situations and transitions of care, also to be covered.

Sri Lanka has achieved remarkable indices in universal health coverage which are far above
the rates achieved by other countries in WHO region and the world bank income group. The
next step for Sri Lanka is to target safer care and quality care. With a high overall literacy
rate in Sri Lanka, this is achievable with development of well-coordinated action plans and
proper monitoring of implementation of such action plans. The Directorate of Healthcare
quality and safety of the Ministry of Health is taking an enormous effort to achieve this goal
to take Sri Lanka to the next level in healthcare. Taking the responsibility and giving
leadership to the development of this national action plan on medication safety is one such
step taken by the Directorate. Involving all relevant stakeholders has made this national
action plan a collective effort of all stakeholders. As the initial draft was made based on
studies and observations relevant to medication safety in Sri Lanka, this action plan is
unique to Sri Lanka and covers the 4 strands and the 3 flagship areas identified by the WHO.

We hope and are confident that all the stakeholders who contributed to development of
this national action plan will be taking steps to implement the activities assigned, to prevent
serious patient harm and deaths due to medication errors in Sri Lanka.

Professor PriyadarshaniGalappatthy
Senior Professor of Pharmacology

Faculty of Medicine, University of Colombo

FOREWORD

Medication safety has become a global concern since medication errors are associated with
high number of mortality and morbidity around the world. Therefore, considering the WHO
request at the second ministerial summit on patient safety, the Ministry of Health, Sri Lanka
decided to give the contribution to develop a national action plan on medication safety
through Directorate of Healthcare Quality and Safety.

The Directorate of Healthcare Quality and Safety functions as the focal point of National
Quality Assurance Programme of the country. It gives technical direction and guidance to
the various level of hospitals through Medical Officer of Quality (MO-QMU) network
connecting the centre with the line ministry health care organizations and MO-QMU units of
each district.

In 2019, the Directorate of Healthcare Quality and Safety started conducting consultative
meetings to develop the national action plan on medication safety based on the draft
prepared by Professor PriyadarshaniGalappatthy, senior Professor in Pharmacology, Faculty
of Medicine, University of Colombo, who is a member of the WHO expert working group on
medication safety, at WHO Headquarters in Geneva.

After conduction of six consultative meetings with relevant stakeholders and other
necessary steps, the document was finalised and the Secretary, Ministry of Health was given
the approval for the final document.

I wish to express my sincere gratitude and appreciation to all the technical experts
comprised of officials of Ministry of Health, Professional Collages & other organizations for
their valuable contributions in developing this National Action Plan on Medication Safety. I
express my special thanks to WHO country office, Sri Lanka, for their contribution in this
national endeavour. Proper implementation of this plan by all the relevant authorities is of
paramount importance to improve the quality and safety of healthcare services. .

Dr.Dewanee Ranaweera,
Director (Covering Up), Healthcare Quality and Safety,

Ministry of Health, Sri Lanka.

LIST OF CONTRIBUTORS

1. Dr. Lal Panapitiya, DDG/MS 1, Ministry of Health

2. Dr.Sudath K. Dharmaratne, Former Director, DHQS
3. Prof. PradeepaJayawardhana, Professor in Pharmacology, MDC/SLMA
4. Prof. Nirmala Wijekoon, Professor in Pharmacology, University of Sri Jayewardenepura
5. Prof. Rohini Fernandopulle, Professor in Pharmacology, KDU
6. Prof.ChamilaMeththananda, Professor in Pharmacology, Faculty of Medicine, University of
Kelaniya
7. Prof. Shalini Sri Ranganathan, Professor in Pharmacology and Consultant Paediatrician,
University of Colombo
8. Prof. ChandaniWanigathunga, Professor in Pharmacology, University of
Sri Jayewardenepura
9. Prof. PradeepaJayawardana, Professor in Pharmacology, University of Sri Jayewardenepura
10. Prof. ManikHettihewa, Professor in Pharmacology, University of Ruhuna
11. Dr. T.K. Kalubowila, Director –DGH-Kalutara
12. Dr. Pradeep Ratnasekara, Deputy Director,CSHW
13. Dr.PriyanwadaJayalath, Deputy Director-Laboratory Services
14. Dr.SanathHettige, Consultant Family Physician
15. Dr.IreshaWalawage, Consultant Anaesthetic
16. Dr. S.J. Balasingham, Consultant Community Physician- HEB
17. Dr.Priyantha Liyanage , Consultant Community Physician, DHQS
18. Dr. Nilantha C. Ratnayake, Consultant Community Physician-Institute of Oral Health
19. Maharagama
20. Dr.Jayaindradra Fernando, Consultant Surgeon
21. Dr.SuranthaPerera, Consultant Paediatrician
22. Dr.SaradhaKannangara, Consultant in Obstetrics & Gynaecology – GMOA

23. Dr.Thushara Matthias, Senior Lecturer Grade II and Consultant Physician

Department of Medicine
24. Dr. T. S. Navaratinaraja, Senior Lecturer in Pharmacology, Faculty of
Medicine, University of Jaffna
25. Dr.NethushiSamaranayaka, Senior Lecturer in Pharmacology, Faculty of
Medicine, University of Sri Jayewardenepura
26. Dr.ChamariWeeraratne, Senior lecturer in Pharmacology, Colombo
27. Dr.Priyanga Ranasinghe, Member- SLACPT
28. Dr HimaliWijegunasekara, SR – Medical Administration
29. Dr. Y. M. M. Priyangani, Senior Registrar- DHQS
30. Dr. Nirmala Loganaden, SR – Medical Administration
31. Dr.SanthushSenapathi, Registrar in Medical Administration
32. Dr.AvanthiRubasingh, Registrar in Medical Administration
33. Dr. N. T. Wellapuli, National Coordinator- WHO
34. Dr. K.C. D. Banneheka MO/QMU- NHSL
35. Dr.CharuniKohambange, Medical Officer, DHQS
36. Dr.Nirmali de Silva, Medical Officer, DHQS
37. Dr. Sinha De Silva, Registrar, Community Medicine
38. Dr.V.P.Eranga, Medical Officer, DHQS
39. Dr.M.R.Najidiyardeen, Medical Officer, DHQS
40. Dr.NipunDasanayake, Medical Officer, DHQS
41. Ms. P.D. Solomon, Assistant Director, MSD
42. Mr. J.R.S. Kumara, Assistant Director, MSD
43. Mr. Dineth Silva, Assistant Director-QA- Emergency Life Science
44. Ms. K.S.K.Weerasekara, Assistant Director, Surgical MSD
45. Mr. Nalin Kannangara, Managing Director-SLPMA
46. Ms. SuranganiePerera, Deputy General Manager, Marketing, State Pharmaceuticals
Corporation
47. Mrs. M.B.S. Samanmalee, Director nursing Medical Service
48. Mrs. Rajapaksha, Director Public Health Nursing
49. Ms. I. M. P. S. Ilankon, Lecture- USJP
50. Mr. D.P.M. Perera, Superintendent of Custom- SL Custom
51. Mr. Krishantha De Silva, Pharmasist-NMRA
52. Mr. MahanamaDodampegama,The Sri Lanka Chamber of the Pharmaceutical Industry
53. Mr. Jayalanka Senanayake, Pharmacist- MSD
54. Ms. ChamindikaPerera, Pharmacist – NMRA
55. Mrs. A. Raveendran,Chief- Pharmacist NHRD
56. Ms. IndunilWaliwaththa, Pharmacist- MSD
57. Mr. S. PriyankaraPerera, The society of government pharmacist
58. Ms. Wasana Bandara, CSTH- Kalubowila
59. Mr. K.U. R. Wickramasinghe, Scientific officer- NDDCB
60. Mr. ShalithAthauda, President- PSSL
61. Mr. R. BuddhikaLakmal, Nursing officer- Government Nursing Officers
62. Mr. Hemantha Wijesekara, AIPPOA
63. Mr.ShamilaThennakoon, AIPPOA
64. Mr. R. Mahendrathna, AIPPOA
65. Mr. AmithPerera, Chief. FQMI
66. Christine Perera, Patient Society
67. Mr. A.P. Attapattu, Development Officer, DHQS
68. Mrs. W.A.C. Niroshani, Development Officer, DHQS
69. H M R I Tennakoon, Development Officer, DHQS
70. C R A Somanayaka, Graduate Trainee, DHQS
71. Mrs. H.A.D.P. Hettiarachchi, Public Relation Assistant, DHQS
LIST OF ABBREVIATIONS

AIPPOA All Island Private Pharmacy Owners Association

AMS Association of Medical Specialists
CCP Ceylon Collage of Physicians
CMCC Ceylon Medical College Council
CME Continuous Medical Education
DHQS Directorate of Healthcare Quality and Safety
ET&R Education, Training & Research
FDC Fixed Dose Combinations
GDSA Government Dental Officers Association
GMOA Government Medical Officers Association
HPB Health Promotion Bureau
LASA Look Alike Sound Alike
MDC Medicinal Drugs Committee
MoH Ministry of Health
MSD Medical Supplies Division
NDDCB National Dangerous Drugs Control Board
NDTC National Drug Therapeutic Committee
NMQAL National Medicinal Quality Assurance Laboratory
NMRA National Medicinal Regulatory Authority
PHRA Private Healthcare Regulatory Authority
PoM Prescription only Medicines
PSSL Pharmaceutical Society of Sri Lanka
QMU Quality Management Unit
RDHS Regional Director of Health Services
SLACPT Sri Lanka Association of Clinical Pharmacology and
Therapeutics
SLADA Sri Lanka Anti-Doping Agency
SLCP Sri Lanka Collage of Paediatricians
SLDA Sri Lanka Dental Association
SLGP Sri Lanka Collage of General Practitioners
SLMA Sri Lanka Medical Association
SLNA Sri Lanka Nurses Association
SLSF Sri Lanka Student Formulary
SOP Standard Operating Procedures
SPC State Pharmaceutical Corporation
SPHI Supervising Public Health Inspector
TOR Terms of Reference
INTRODUCTION

Medication safety has become a global issue contributing to unacceptably high number of deaths
and disabilities in the world. Medical error is the third leading cause of death in United State of
America with 180,000 deaths occurring annually. Errors occurring in lower- and middle-income
countries are considered much higher than these reported figures from high income countries.

Major causes of medication errors include communication errors, including oral and written
communication; confusion with the name, such as look-alike and sound-alike drug names; labelling
errors; errors due to human factors, such as knowledge deficits and dose miscalculations; and errors
related to the improper packaging or design of the drug product.

Taking these factors in to consideration, the World Health Organization (WHO) launched medication
safety as a global patient safety challenge at the 2nd Ministerial Summit on patient safety in 2017. At
this international summit, all countries were requested to make a pledge to reduce medication
errors and develop national action plans to reduce severe harm due to medication errors by 50%
within 5 years

Professor PriyadarshaniGalappatthy, Senior Professor of Pharmacology, Faculty of Medicine,

University of Colombo, who is a member of the WHO expert working group on medication safety, at
WHO Headquarters in Geneva has taken the initiative to develop a draft national action plan on
medication safety for Sri Lanka and submitted it to the Ministry of Heath for necessary action.

The Directorate of Healthcare Quality and Safety, Ministry of Health as the focal point, conducted six
consultative meetings with relevant stakeholders to finalize the draft, with the financial and
technical support provided by the WHO.

The draft was re-circulated to all relevant stake holders and considering all the inputs and
recommendations received, final document was prepared. Approval was taken from secretary of
health to publish this prepared document as the National Action Plan on Medication Safety.
NATIONAL ACTION PLAN ON MEDICATION
SAFETY FOR SRI LANKA

3
 Action Plan on Medication Safety for Sri Lanka (2021-2025)

Plan based on the WHO global patient safety challenge on “Medication without harm”, by targeting the four strands identified by the WHO.

Objective: To minimize serious medication errors in public and private healthcare sectors in Sri Lanka

WHO Objective: To prevent serious medication errors by 50% within 5 years.

Activities to be conducted targeting both the public and private sector healthcare institutions through the following;

Public sector – Directorate of Healthcare Quality and Safety (DHQS)

National Medicinal Regulatory Authority (NMRA)
Medical Supplies Division (MSD)
Medical and Allied Health Faculties of Universities
Director Education and Training (ET and R)
Ministry of Health

Private sector Hospitals – Private Healthcare Regulatory Authority

Ministry of Health (MoH)

Private sector pharmacies – Through State Pharmaceutical Corporation (SPC)

National Medicines Regulatory Authority (NMRA)

Other – Professional Associations, Colleges and patient groups

1
NATIONAL ACTION PLAN ON MEDICATION
SAFETY FOR SRI LANKA (2021-2025)

NATIONAL ACTION PLAN ON MEDICATION SAFETY FOR SRI LANKA (2021-2025)

2
 Persons/Institut

implementation
/Organizations

Responsibility
Stakeholders/
Sub activities

Performance

responsible
Time frame

Indicators
Proposed
activity
Strand

(KPIs)

ions
Key

for
1. Systems 1.1 1. Introduce a separate 1. Percentage of Director General of Director- DHQS
and Introduce 2021 medication incident hospitals Health Services
practices medication – reporting form. having a (DGHS), Heads of Institutions
incident 2023 functional Deputy Director
reporting 2. Integrate the medication Incident General / Medical Medical Officer -
system into incident reporting in to reporting Services -1 Quality Management
hospitals and adverse event reporting system. (DDG/MS -1), Units in hospitals
implement process in hospitals. DDG/MS - 11,
action plans to 2. Number of DDG/Dental Services, The Society of
prevent 3. Issue a circular from DGHS medication Director - Medical Government
occurrence of introducing the medication safety Supplies Division Pharmacists
similar events. incident reporting form to incidents (MSD),
all hospitals including reported Directorate of All Island Private
private hospitals and Healthcare Quality Pharmacy Owners
encourage reporting with 3. Number of and Safety (DHQS), Association (AIPPOA)
reporting guidelines, which sentinel Quality Management
would indicate assessment events Units (QMU) in State Pharmaceutical
of reports in a no blame reported hospitals, Cooperation
culture. Government
4. Number of Pharmacists,
near misses Sri Lanka Medical
4. Use MSMIS electronic reported Association (SLMA),
system to report in Sri Lanka Dental
hospitals where these Association (SLDA),
facilities are available. Ceylon College of
Physicians (CCP),
5. Reinforce establishment Sri Lanka College of
and function of Drugs and Pediatricians (SLCP),
therapeutic committee in Sri Lanka College of
all hospitals where General Practitioners
reported incidents are (SLGP),

3
 discussed to take Pharmaceutical
preventive actions. Society of Sri Lanka
(PSSL),
6. Distribution of medication The Departments of
incident reporting Pharmacology in
guidelines to all colleges Universities,
and display it in the Sri Lanka Association
websites. of Clinical
Pharmacology and
Therapeutics
7. Encourage reporting from (SLACPT)
private pharmacies. Consultants in
8. Establishment of a national Clinical
incident reporting Pharmacology and
database. Therapeutics

9. Initiating an Incident
reporting systems from
private sector
hospitals/pharmacies.
10. Development of a guideline
on how to process incident
reports and giving
feedback.

11. Encouraging mechanism to

acknowledge the incident
reporters.

1.2 2021 1. QMUs of hospitals and 1. Number of Director – DHQS

Discuss serious - DHQS to actively collect sentinel events
errors firstly at 2023 reports and discuss at discussed at Academics from
quarterly basis, Institutional levels to Medication Departments of
at local identify contributory Safety Steering Pharmacology, and
hospital QMU factors and preventive Committee and pharmacy in
and forward to actions to be taken. NDTC. universities
DHQS.
4
 2. Forward the reports to 2. Number of Medicinal Drugs
Establish a DHQS for discussion at circulars issued Committee
National National Medication Safety to standardize (MDC)/SLMA
Medication Steering Committee. safety practices.
Safety Steering
Committee at 3. Establish a National 3. Number of The Society of
Ministry of Medication Safety Steering medication Government Pharmacist
Health to Committee in the DHQS to safety
discuss the discuss reports and to newsletters/rep Director Nursing -
incident suggest preventive actions. orts published. Medical Service
reports and to
suggest 4. Quarterly institutional
preventive meetings and national NMRA
actions. steering committee MSD
meetings to be held at
The reports D/HQS to discuss incidents
and proposed and reports to be sent to
actions to be NDTC.
forwarded to
National Drugs 5. Medication safety incidents
and to be discussed at NDTC
Therapeutics meetings maintaining
Committee anonymity of reporters and
(NDTC) staff involved.

6. A report of medication
safety steering committee
meeting to be attached to
the NDTC meeting minutes.

7. Introduce the concept of

“Medication Safety
Newsletter” which will be
circulated to all hospitals.
Only the incident and
preventive measure to be
discussed in the
newsletter.

8. Publish key incidents with

suggested preventive
5
 actions in Sri Lanka
Prescriber.

1.3 2021 1. Circular issued on “A 1. Percentage of DGHS, DHQS

Implement the - Doctor’s name stamps OPD and clinic National Drug GMOA
necessity of 2023 mandatory pre-requisite to prescriptions Therapeutic SLDA
placing the seal dispense drugs" with a stamp. Committee (NDTC) - GDSA
(with Name & MoH Professional Colleges
SLMC 2. Rate of Director - DHQS,
registration legibility of DDG - MSD,
number) of prescriptions Government Medical
responsible identified in Officers Association
consultant (eg: prescription (GMOA),
VP-OPD) on the audit. Association of
prescription to Medical Specialists
identify the (AMS),
prescriber, to Sri Lanka Dental
improve Association (SLDA),
legibility of Government Dental
handwriting; Surgeons Association
by (GDSA)
Issuing a
circular
mentioning not
to issue drugs
from hospital
pharmacies
without the
accurate seal.

1.4 2021 1. Develop accepted “Standard 1. Percentage Academics from

Prepare a list of – abbreviations” list and list of availability of Pharmacology and
standard 2023 “Never use abbreviations" the List of Pharmacy
abbreviations “approved Departments of
that could be 2. Circulate the lists to all abbreviations” Universities and others
used hospitals and the List of who have done/doing
“never use work in this area

6
 abbreviations”
in hospitals.

1.5 2021 1. Develop a List of high-risk 1. Percentage of Academics from

Prepare high - drugs " hospitals Pharmacology and
risk medication 2023 2. Develop Standard practicing SOPs Pharmacy
list Operating Procedures on high-risk Departments of
(SOP) for handling and medicines Universities and others
storage of high-risk who have done/doing
medicines work in this area

1.6 2021 1. A circular to be issued 1. Percentage of NMRA, AIPPOA NMRA

Implement the – making it necessary to Pharmacies Food & Drug
necessity for a 2022 display a list of “Over the dispensing Inspectors (F&DI) of
prescription to counter medications” at medicines Regional Director of
dispense each pharmacy. without a Health Services
“Prescription only prescription. (RDHS),
Medicines” 2. A poster identifying "Over Supervising Public
(PoM) the counter drugs list" 2. Number of Health Inspectors
in the private displayed at all pharmacies pharmacies (SPHI)
sector. by Collaboration with the displaying
All-island Pharmacy “Over the
. Owner's Association counter
(AIPPOA) medications”
list.
3. Create the Drug Inspector
Cadre
4. Prepare TOR for Drug
Inspectors.
5. Once in 2 months meetings
of steering committee to
discuss medication

7
 incidents reported and
issues at MoH and report to
be sent to “National
Medication Safety Steering
Committee”.

1.7Assign a 2021 1. Prepare Terms of 1. Percentage of Director - DHQS Director, HQS, Heads of
medication - Reference (TOR) for QMUs with an Government each QMU in hospitals
safety 2023 medication safety liaison assigned pharmacists and Directors of
pharmacist to pharmacist for QMU liaison The Society of hospitals
each QMUs and implement appointing pharmacist Government
established in liaison pharmacist through dedicated to Pharmacists
major hospitals a ministry circular. medication
and have safety
assigned 2. Develop the job activities
activities descriptions for this post.
2. Number of
medication
safety
activities done
by the
pharmacist
1.8 2021 1. Issuing a circular for 1. Percentage of Private Healthcare Private Healthcare
Encourage - consultants to use private Regulatory Authority Regulatory Authority,
private sector to 2023 electronic prescribing hospitals with (PHRA), MoH
use electronic when available. electronic College of GPs,
prescriptions by prescription
all consultants, 2. Appreciation of private facilities. Director/Information
through a sector for implementing Health -MOH
circular by electronic prescribing.
Private
Healthcare 3. Development of a software
Regulatory Unit for General Practitioners
of Ministry of for electronic prescribing.
Health
1.9 2021 1. Mechanism to appreciate 1. Number of PHRA, MoH, Private Healthcare
Encourage - the private sector hospitals accredited Regulatory Authority
accreditation of 2025 which are internationally Hospitals. DDG / MS - 2 MoH, DDG MS 2
private sector accredited.
hospitals, with

8
incentives for
getting
accredited (e.g.
JCI, ACHS)

1.10 2021 1. Introduce “Electronic 1. Number of MoH Director - Health

Encourage - Prescribing” to as many hospitals with Information
electronic 2025 hospitals as possible. electronic
prescriptions prescribing
in government facilities.
hospitals
where
computerizatio
n of records is
done as a pilot
project
1.11 2023 1. Create cadre positions, 1. Number of MoH, Ministry of Health
Employ - increase training of hospitals with Government
graduate 2025 graduate pharmacists. clinical Pharmacists Government
pharmacists as pharmacists. Association, Pharmacists
clinical 2. Build consensus through PSSL Association
pharmacists to trainings and workshops.
the wards to PSSL
attend 3. Suggest introduction of a
medication Special degree,
reconciliation Postgraduate diplomas and
at transitions MSc in “Clinical Pharmacy”
of care; at university level.
providing
information
and taking
preventive
actions, for
medication
safety.

1.12 2021 1. Translations to 1. Number of School for Deaf and Academics,

Introduce - brail/pictograms. hospitals that blind researchers and other
appropriate 2025 have healthcare workers
processes for established this

9
safe 2. Pictorial/brail labels safe medication involved in work in
medication use available use services for these areas
among patients to be used in special groups. disabled
with visual, patients.
hearing
and other
disabilities.

1.13 2021 1. Development of “Standard 1. Number of Director -DHQS, Academics,

Identify a list of - practices package for hospitals Academic researchers and other
minimum 2025 medication safety” for implementing Departments of healthcare workers
practices for hospital settings and private the practice Pharmacology and involved in working in
hospitals to pharmacies. package. Pharmacy in these areas
ensure Universities.
medication
safety.

(A medication
safety practice
package for use
throughout the
drug
management
cycle)

1.14 2021 1. Identification of indicators 1. percentage of Director - DHQS, Academics,

Identify - hospitals using Academic researchers and other
medication 2025 the medication Departments of healthcare workers
safety safety Pharmacology and involved in working in
indicators for indicators. Pharmacy in these areas
Sri Lanka. Universities.

1.15 2022 1. Strengthening the Drug 1. Number of National Medicinal NMQAL-Head, NMRA-
Strengthening - quality quality Quality Assurance chairman, Govt
a Drug 2025 assurance program. failures Laboratory (NMQAL), Pharmacists
quality reported. NMRA,
assurance Society of
program to 2. Number of government
tackle poor quality pharmacists

10
 quality testing
medicines done.

1.16 2022 1.Develop guidelines and 1. Number of NMRA, AIPPOA

Determine the - regulations for online “online Academics,
extent of 2025 prescriptions and Pharmacies” researchers and other
problems dispensing. detected. healthcare workers
associated with involved in work in
online 2.NMRA to take action on 2. Number of these areas
prescribing online dispensing. instances
and dispensing action taken.
and take
appropriate
action.

2. 2.1 2021 1. Developing a list of Look 1. Number of Government Academics,

Medicines Activities to - Alike Sound Alike (LASA) hospitals Pharmacists, researchers and other
identify look 2024 drugs used in the Sri Lankan practicing “Tall PSSL, healthcare workers
alike sound settings and recommend tall man lettering” DHQS, involved in work in
alike (LASA) man lettering for those. for LASA drugs. NMRA, these areas
medicines and SLMA,
take steps to 2. Distribution of the list of 2. Number of SLDA,
prevent mix identified LASA drugs to hospitals CCP,
ups; hospitals through DHQS. storing LASA Other professional
medicines colleges
i. Use Tall 3. Sending a request to separately.
man hospitals to store LASA
lettering to medicines separately. 3. Number of
identify incidents
LASA drugs 4.Establishing a mechanism to identified and
ii. Storing prevent allocating “Sound prevented from
separately alike” brand names at the allocating sound
iii. Scrutini point of registration of alike brand
ze during medicines by the NMRA. names at the
registration point of
of medicines 5.Establishing a mechanism at registration by
by the NMRA; to prevent registering the NMRA.
NMRA critical medicines (such as
warfarin tablets) with same 4. Number of
color for different strengths; similar looking
registering drugs (Eg: medicines
11
 Paracetamol) with same prevented
color for different registration by
strengths; and registering the NMRA.
drugs having similar
appearance. (Eg. KCL,
NaCl)

2.2 2022 1. Number of NMRA, NMRA,

Taking action - 1. Ensuring that NMRA drug detections SPC, AIPPOA.
to prevent 2025 registration details are up to made by the PSS,L
unregistered date. authorized AIPPOA.
medicines 2. officers
being available 2.Publishing timely up to regarding
in the market date list of registered 3. unregistered
through medicines in the website of medicines.
surveillance. NMRA.
4. Number of
3.Establishment of an complaints
automated electronic received by the
response system from NMRA
NMRA regarding registered regarding
drugs. unregistered
medicines.
4.Carrying out market
surveillances by authorized
5. Number of
officers.
investigations
conducted by
NMRA against
complaints on
unregistered
medical
products.
2.3 2021 1. Steps taken to limit the 1. Number of NMRA, NMRA,
Limit the large - number of brands registered brands registered MSD MSD.
number of 2024 under a single generic pertaining to
brands product by NMRA. single generic
available of the product.
same drug, by
stringent
evaluation of

12
quality to avoid
confusion
between
different
brands.

2.4 2021 1. Availability of Through medication Academics,

Prepare a list - 1. Preparing a List of “high- “List of high- error reporting researchers and other
of “high risk 2024 risk risk medicines” system – D/HQS healthcare workers
medicines” for medicines”. at the relevant CCP, involved in work in
serious errors. institutions. SLCP, this area
2. Preventing use of; same SLGP,
i. Identify color code for different 2. No. of PSSL,
through strengths of products, Institutions that SLDA,
incident which can be confusing have been University academics,
reporting. during registration by informed about NMRA,
NMRA. serios errors MSD,
ii. From due to high-risk AIPPOA.
published 3. Develop specifications medicines (to
literature on when calling for tenders; prevent similar
high-risk such as color cording, errors in the
medicines. limiting strengths, future)
individual packages etc.
iii.Educate whenever possible. 3. Number of
Health Care medication
Personnel on incidents
“high risk reported
medicines” regarding high –
and take risk medicines.
preventive
actions.
(Eg.
Individual
packaging,
Colour
cording
whenever
possible)

2.5 2021 1. Asking for suitable changes 1. Number of Govt. pharmacists, NMRA,
– in the label when problems in NMRA, MSD
13
Requesting 2025 necessary at the point of formulations MSD, SPC,
necessary registration and calling for identified and AIPPOA. Govt Pharmacists,
formulation tenders. rectified. AIPPOA.
adjustments,
labeling 2. Not-registering irrational 2. Information on
changes, fixed dose combinations the details made
specifications (FDC). available
of medicines, through the
when calling (Such as antidiabetics with newsletter
for tenders for anti-hypertensives, FDC
prevention of including paracetamol etc.)
medication
errors
2.6 2021 1. Steps taken to inform about 1. Number of CME Universities, Academics,
Identify and the most commonly activities and SLACPT, researchers and other
publicize the - prescribed medicines and articles SLMA drugs healthcare workers
list of most errors noted, at Continuous published committee, involved in working in
commonly 2022 Medical Education (CME) focusing on, SLDA, this area
prescribed activities and articles commonly PSSL,
medicines in published. prescribed AIPPOA,
the private and medicine and SGP
public sector common errors
and common noted.
errors noted to
educate health
care
professionals
and public on
these
medicines

2.7 2022 1. Increase the number of 1.Number of Post NMRA, Academics,

Provide more - collecting Post market market samples MSD, researchers and other
facilities, 2025 samples and analysis for collected and NMQAL. healthcare workers
resources and quality of the drugs. analyzed during a involved in work in
surveillance, certain time these areas, Head of
for detection of 2. Market surveillances for period. NMQAL, Chairman,
quality failure counterfeit medicines and CEO of the NMRA,
and counterfeit products with quality 2.Number of Govt pharmacists
medicines (Eg. failures. market AIPPOA.
using a QR surveillances
14
 codes) and 3. Actions taken to withdraw done by
taking action stocks due to quality authorized
when failures. officers.
identified.
4. Actions taken to prevent 3.Number of
purchase of medicines from batch -
supplies with quality withdrawals and
failures product-
withdrawals.

4.Number of
products
blacklisted.

3.Health 3.1 1. Adopting the “WHO patient 1. Number of Medical Faculties of Academics of
care Incorporating 2021 safety curriculum on universities, Universities Departments of
profession “WHO patient - medication safety” in to degree programs Pharmacology and
als safety 2023 universities, degree programs and higher Sri Lanka Association Pharmacy in
curriculum” on and higher diploma curricula. diplomas, adopted of Clinical Universities, Deans of
medication the “WHO patient pharmacology and Allied Health Faculties,
safety into the 2 Incorporating medication safety curriculum Therapeutics Director, ET and R,
undergraduate safety into Good Intern on medication (SLACPT), Director Nursing
and higher training program and Registrar safety” in to their Principles of Pharmacy
diploma training. curricula. All Allied Health and nursing schools,
curricula of all Faculties of
faculties of Universities
medical, conducting courses in
pharmacy and pharmacy and
nursing. nursing through the
respective
universities.

Education Training &

Research (ET&R)
Unit.

SLACPT, medical
Allied Health –
Pharmacy (AHSP)
Allied Health –
Nursing (AHN)
15
3.2 2021 1. Conducting different types of 1. Level of SLACPT, Academics,
Activities to - awareness programs for Legibility of Society of Govt. researchers and other
improvement 2025 health professionals on prescriptions Pharmacists, healthcare workers
of legibility of consequences of illegible shown in PSSL, involved in work in
handwritten prescriptions: prescription SPC, these areas
prescriptions. audits. MoH,
 Good Intern training GMOA,
program 2. Survey results Sri Lanka Nursing
 Registrar training on number of Association,
 College of General hospitals using
Practitioners programs computerized SLMA,
 All professional colleges prescriptions and SLDA,
printed The Society of Govt.
2.Introduction of the uniform dispensing labels. Dispensers Union.
prescription format for Sri
Lanka to be used in hospitals.

3.Issue a ministry circular to

hospitals to incorporate
electronic prescriptions.

4. Pictorial/brail labels
available to be used in
special groups.

3.3 2022 1. Introduction of a uniform 1. Survey results Society of Govt. Academics,

Dispensing - dispensing label format for on medicines Pharmacists, researchers and other
medicines with 2025 Sri Lanka. dispensed with PSSL, healthcare workers
labels and print complete AIPPOA, involved in work in
information in 2.Issuing of a Circular from dispensing SPC. these areas,
all 3 Ministry of Health. labels. Govt pharmacists,
languages/ AIPPOA.
pictorials/brail 3.Regulation on essential 2. Number of
le method. information to be provided patients who
in all 3 languages on were given
dispensing labels. pictorial
/braille labels
4.Facilitating printing of in pharmacy for
dispensing labels.

16
 dispensing to
5.Pictorial/brail labels needy patients.
available to be used in special
groups.

3.4 2021 1. Introducing a standard SLACPT, Academics,

Not dispensing - operating procedure (SOP) 1. Availability of a Society of Govt. researchers and other
unclear 2025 to tackle illegible prescriptions. standard Pharmacists. healthcare workers
prescriptions. operating PSSL, involved in work in
2.Training programs for procedure (SOP) SPC, these areas,
pharmacists on “assertive to tackle MoH, Govt pharmacists,
communication” when illegible GMOA, AIPPOA.
handling illegible prescriptions. SLNA,
prescriptions. SLMA,
2. Number of SLDA.
3. Issuing an awareness training The Society of
circular from the Ministry of programs Dispensers Union,
Health on “Do Not Use conducted for GMOA,
abbreviations” and pharmacists on SLNA,
“Standard abbreviations” for “assertive SLMA,
HPs. communication The Society of
” when Dispensers Union
handling
illegible
prescriptions.

3.Availability of a
circular issued
from the Ministry
of Health on “Do
Not Use
abbreviations”
and “Standard
abbreviations” for
HPs.

3.5 2021 1. Establishing patient- 1. Number of SLACPT, Government

Providing - medication counseling hospitals with Society of Govt. Pharmacists
essential 2025 facilities in hospitals. fully functional Pharmacists, Association, AIPPOA
17
information to patient PSSL,
patients with 2.Utilizing translations/brail/ counseling SPC,
medication Pictograms in medication facility/ MoH,
counselling. counselling. pharmaceutical GMOA,
care units. SLNA,
SLMA,
SLDA,
The Society of
Dispensers Union.
3.6 2022 1. Conducting workshops on 1. Number of PGIM, SLACPT, Specialty
Postgraduate - medication safety training Universities, Board in Clinical
courses to have 2025 for postgraduate students. workshops SLACPT, Pharmacology in PGIM
inputs on conducted on Diploma in
medication 2. Providing inputs on medication Healthcare quality
safety and medication safety to safety. and safety,
training postgraduate courses. UoC,
workshops on DHQS.
medication
safety.
3.7 2021 DHQS,
Encourage - 1.Conducting awareness 1.Number of Professional Medication incident
medication 2025 programs on importance of awareness Associations evaluation central
incident incident reporting. Programs (CCP, SLGP, SLCP, committee of the
reporting by all conducted on PSSL, SLMA, SLDA, steering committee
categories of 2.Conducting meetings on importance of SLNA + 3.2)
HCP processing incident reports incident
at hospitals and nationally. reporting.

3.Organization of symposiums
on medication safety best
practices.

3.8 2021 1. Including medication 1. Number of PG ET & R, Director ET and R,

Include - safety as a compulsory area training courses Govt. Pharmacists, Pharmacy tutors and
“medication 2023 for portfolios in which have MoH, academics teaching in
error undergraduate and post included CMCC, pharmacology and
prevention graduate training courses. medication safety pharmacy

18
strategies as a compulsory Department of
employed”, as area for portfolios. Pharmacology,
one UoC.
compulsory
area of
portfolio
entries in log
books; by
intern
pharmacists,
trainee nurses,
medical
students and
post graduate
medical
trainees.

3.9 1. Conducting awareness 1. Number of All professional Academics,

Emphasize on programs/ measures or awareness Associations, researchers and other
minimum of training on checking 5 rights programs/ healthcare workers
Five Rights among HPs. measures or Universities, involved in working in
(right patient, training on this area
right drug, 2 Development of SOPs for checking 5 Pharmacists and
right dose, each point of care. rights among nurses training
right route and HPs. schools.
right time at all
stages of 2. Availability of
medication SOPs at each point
process) and of care.
other Rights
(right for
information,
right to refuse
etc.) to include
during all
training
programs.

19
3.10 2021 1. Number of Department of Formulary committee
Disseminate - 1. Disseminating the medicines universities Pharmacology, UoC of the Department of
the Sri Lanka 2025 formularies to libraries of with the SLSF MSD, Pharmacology
student universities. available in MoH. University of Colombo
formulary their libraries.
(SLSF) 2018 2. Disseminating the drug
which focuses formulary to hospitals. 2.Number of
on “most hospitals where
commonly 3. Disseminating the drug formulary is
prescribed formulary to private available.
medicines pharmacies
currently in the 3. Number of
country and private pharmacies
highlighting using the SLSF.
high risk
medicines”, 4. Number of total
aimed at all copies
categories of distributed
students
trained as
health care
professionals.
(To be updated
once in 5
years)
3.11 2021 DHQS, Directorate HQS,
Regular - 1. Conducting regular 1. Number of SLMA Drugs University
training 2025 workshops on medication training Committee, Departments
programs and safety. programs and SLDA,
workshops workshops SLACPT,
aimed at 2.Improving the coverage of conducted on and Universities.
healthcare workshops in the country. medication to give expertise
professionals safety to
(nurses, different
pharmacists, healthcare
and medical professionals.
officers) on
medication 2. Number of
safety healthcare
workers who
attended
20
 training
programs

3. Coverage of
workshops in the
country.
3.12 2022 1. Conducting training 1. Number of University SLMA Drugs
Training - courses /workshops on training Departments of committee, Govt
courses/ 2025 preventing medication courses Pharmacology, Pharmacists, AIPPOA
workshops on errors for external conducted for ET&R,
preventing Pharmacists and sales external and SLMA Drugs
medication assistants in the private private sector Committee,
errors for sector pharmacies. pharmacists. SLDA,
external SPC,
Pharmacists Pharmaceutical
and sales Society of Sri Lanka
assistants (PSSL)
working in the
private sector
pharmacies.
3.13 2021 1. Conducting CPD activities for 1. Number of CPD SLMA, SLMA and other
CPD activities - doctors on Medication activities SLDA, Colleges
with other 2023 safety in collaboration with conducted in CCP,
relevant Colleges. collaboration PSSL,
Colleges to with Colleges. College of Medical
ensure Administrators,
medication College of
safety targeting Anesthetists.
doctors - Liaise
with 3.11

3.14 2021 1. Ensuring the availability of 1. Number of drug Professional Academics,

Activities to - updated treatment guidelines use studies Associations and researchers and other
minimize 2025 for HPs. conducted in Colleges, healthcare workers
polypharmacy respective Medical Faculties, involved in working in
to reduce 2. Conducting awareness hospitals to assess Allied Health this area
medication programs on polypharmacy in polypharmacy Faculties,
errors.

21
 collaboration with other 2. Number of Ministry of Health,
colleges. DTCs initiating PSSL.
studies on
3. Ensuring the availability of polypharmacy
explicit criteria for assessment with established
on polypharmacy benchmarks
prescriptions.
3.Number of
4.Conducting education and awareness
awareness programs on programs
rational and ethical practices conducted on
to doctors. polypharmacy.

3.15 2022 1. Conducting training courses 1. Number of Post Basic School of Director/Nursing
Training - at Post Basic School of Nursing post-basic nursing Nursing.
course for 2025 on “Prevention of medication schools
nurses through errors” during administration conducting these
Post Basic of medicine. training courses
School of for trainees.
Nursing on
“Prevention of 2. Survey results
medication on safe admin
errors” during practices of.
administration nursing officers
of medicine.

3.16 2022 1. Number of Ministry of Health, Academic Departments

Initiate a - 1. Initiating training of universities Allied health faculties, conducting Pharmacy
sustainable 2024 pharmacy students on “Clinical training SLCPT, curricula
Clinical pharmacy” in the pharmacy University Grants
Pharmacy undergraduate curriculum. students on Commission.
training “Clinical SGP,
program 2. Making opportunities pharmacy” in the PSSL.
available for further training in undergraduate
clinical pharmacy for curriculum.
graduates.
2.Number of
Training of
22
3. Ensuring availability of Trainers”
“Training of Trainers” programs on
programs on clinical pharmacy clinical pharmacy
for selected graduates joining conducted for
the state sector. selected
(in collaboration with clinical graduates joining
pharmacists) the state sector.

4. Establishing pharmaceutical 3.Number of DRPs

care units /clinics in hospitals detected and
in state sector. resolved by
clinical pharmacy
5.Establishing a cadre position services identified
for clinical pharmacists. by studies

4.Number of
hospitals in the
state sector with
pharmaceutical
care units /clinics.

5.Number of
patients receiving
pharmaceutical
care services.

6.Number of
potential hospital
re-admissions
prevented
through clinical
pharmacy
services.

23
4. Patients 4.1 Collect 2021- 1.Identifying gaps of the 1. Number of studies University Academics,
available 2022 previous studies with the conducted on patient Departments of researchers and
studies involvement of postgraduate safety and correct use Pharmacology/ph other healthcare
conducted to trainees and convey the of medications. armacy workers involved
assess patients’ identified research priorities in working in this
knowledge on to Director, Education, area
1. n
medicines and Training & Research (ET& A
methods to R) –Ministry of health s
improve the s
knowledge. e
Carrying s
out new s
studies on i
Patient n
Safety and g
correct use t
of patients’ h
own e
medication
s
4.2 Activities to 2021- 1.Translating patient 1. Number of booklets i. SLMA Drug Academics,
improve 2026 formularies into Sinhala and proving information to committee researchers and
medication Tamil. patients ii. SLDA other healthcare
literacy of iii. Health workers involved
patients by 2.Conducting patient 2. Number of leaflets Promotion in working in
variety of counseling sessions and provided to patients Bureau (HPB) these areas,
methods educational programs/ on medicines iv. Patients for SLMA
i. Publishing workshops on safe patient safety –
books in Medication use for patients, 3. Survey of literacy Ms Christine
Sinhalese at institutional level rate in patients after v. University
and Tamil interventions Departments of
on 3.Conduct Pharmacology/
commonly Seminars/awareness 4. Survey on number of pharmacy
used programs for, patients asking vi. SLACPT
medicines i. School children questions about their vii. PSSL
ii. Providing ii. Elderly medications. viii. Society of
labeled iv. Pregnant mothers Government
medicines 4.Education programs for 5. Number of articles pharmacists
iii. Providing special groups (Visually in newsletters ix. SPC
leaflets on impaired, Hearing impaired) educating patients on x. Media – print
correct use medicines and electronic
24
 of 5. Educating patients on how xi. National
medications to discard left pills. 6. Number of media Dangerous
for high risk campaigns done Drugs Control
medicines 6. Writing medication names Board
and other in patients’ native language 7. Number of medical (NDDCB)
drugs (Sinhala or Tamil) on the and pharmacy Sri Lanka
requiring package /envelope of students providing Antidoping
specific medications. information on Agency (SLADA),
information. medicines to their Ministry of Sports
E.g.: GTN, 7.Use teach back technique patients identified in
ORS, to ensure patients’ surveys.
Warfarin, understandability of their
Alendronate medications
, (at least 5 rights and
Methotrexat purpose of taking the
e, BB cream medications.)
iv. Workshops 8.use short video clips in
for doctors, patients’ waiting area to
nurses and educate patients on correct
pharmacists use of medications
to train
them on
providing
information
to patients
v. Media
campaigns
targeting
patients
using
television,
radio
programs
and print
media (e.g.
Posters) to
increase
medication
literacy
through
Health
25
 Promotion
Bureau
(HEB)
focusing on
5 must
know facts
on
medicines.
vi. Providing
medication
plan in
patients
own
language
(eg; writing
the names of
medications
in Sinhala or
Tamil on the
envelop/on
the package)
with the
help of
pharmacy
and medical
students.

4.3Involvement 2021- 1.informing of High alert 1. Number of 1. SPC Academics,

of pharmacists 2025 medications (HAM) and pharmacists educating 2.PSSL researchers and
in private LASA medicines when patients on HAM and 3.Universities other healthcare
sector and dispensing by pharmacists LASA medicines on 4. QMUs of workers involved
QMUs of to educate patients dispensing these government in working in
government hospitals these areas
hospitals in 2.Listing HAM and LASA lists 2. Number of
education of in the pharmacy units to pharmacies having
patients remind pharmacists to Lists of HAM and LASA
especially on educate patients. lists to remind
high alert pharmacists to educate
medicines to 3. Medication reconciliations patients
prevent serious to be done by doctors for
errors patients at discharge
26
 3. Survey on number of
4.Conducting educational patients who are
workshops, seminars for aware that they are
patients. taking High Alert
medications

4.Number of
workshops /seminars
conducted for patients.
4.4Emphasize 1. Empowering 1. Number of awareness All professional Academics,
on five patient/caregiver on five programs conducted Associations, researchers and
moments of moments for medication to empower other healthcare
medication safety to reduce the risk of patients/caregivers. Universities, workers involved
safety (starting harm associated with the use in working in this
a medication, of their medications. Pharmacists and area
taking my nurses training
medication, schools.
adding a
medication,
reviewing my
medication,
stopping my
medication)

27