D5 Laura Botwinick Peter Angood

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Published on October 2, 2007

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World Alliance for Patient Safety: Advancing Patient Safety Solutions:  World Alliance for Patient Safety: Advancing Patient Safety Solutions International Forum on Quality and Safety in Health Care Barcelona, Spain 19 April 2007 Peter B. Angood, MD and Laura K. Botwinick Co-Directors, Joint Commission International Center for Patient Safety World Alliance for Patient Safety:  World Alliance for Patient Safety The World Alliance was launched in October 2004 in response to a resolution of the WHO’s World Assembly which urged Member States to pay the closest possible attention to the problem of patient safety and to establish and strengthen science-based systems necessary for improving patient safety and the quality of health care. World Health Organization: World Alliance for Patient Safety:  World Health Organization: World Alliance for Patient Safety Patients for Patient Safety Global Challenge Safety Research Reporting and Learning International Classification System Patient Safety Solutions To learn more: http://www.who.int/patientsafety/en/ Collaborating Centre Designation:  Collaborating Centre Designation The Joint Commission and Joint Commission International were designated as the Collaborating Centre for Patient Safety Solutions in August 2005 Charge as a WHO Collaborating Centre:  Charge as a WHO Collaborating Centre Identify Current Regional Safety Problems & Pre-Existing Potential Solutions Understand Regional Barriers to Solutions Assess Risk for Solutions & Gaps Adapt Solutions to Local/Regional Needs Develop Dissemination Strategies Through Global & Regional Collaboration Challenges of Solution Identification:  Challenges of Solution Identification Selecting solutions with broad application Adapting solutions for all countries Developing Transitional Developed Input from International Collaborative Network:  Input from International Collaborative Network Ministries of Health International Professional Organizations International Patient Safety Organizations International Accrediting Bodies International Steering Committee Input from International Collaborative Network:  Input from International Collaborative Network Regional Advisory Groups European Advisory Group Middle East Advisory Group Asia Pacific Advisory Group Input from Latin America and Africa through WHO Focal Points Expert Panels Communications Expert Panel Medication Safety Expert Panel Patient and Family Advisory Group Solutions Development Process:  Solutions Development Process International Steering Committee – June 2006 Regional Advisory Groups – Summer and Early Fall Review by Patient and Family Advisory Group – Fall Review by Communications and Med Safety Expert Panels – Fall International Field Review – Nov 22, 2006 through Feb 16, 2007 Approval by International Steering Committee – April 4-5, 2007 Action on Patient Safety – High 5s:  Action on Patient Safety – High 5s High 5s Project Goals:  High 5s Project Goals To achieve significant, sustained, and measurable reduction in the occurrence of 5 patient safety problems over 5 years in at least 7 countries and build an international, collaborative learning network that fosters the sharing of knowledge and experience in implementing innovative, standardized, safety operating protocols. High 5s Solution Topics:  High 5s Solution Topics Communication During Patient Hand-overs Performance of Correct Procedure at Correct Body Site Medication Reconciliation Control of Concentrated Electrolyte Solutions Hand Hygiene High 5s Participating Countries:  High 5s Participating Countries Australia Canada Germany Netherlands New Zealand United Kingdom United States Phases of High 5s Initiative:  Phases of High 5s Initiative Phase One – Launch and Development of Standardized Protocols Phase Two – Learning Phase Three – Evaluation and Spread High 5s Evaluation Strategy:  High 5s Evaluation Strategy SOP implementation measures Ongoing monitoring of adverse events and Root Cause Analyses (RCAs) Cultural assessments Economic impact indicators 2007 Solution topics (inaugural set):  2007 Solution topics (inaugural set) Look-Alike, Sound-Alike Medication Names Patient Identification Communication During Patient Hand-Overs Performance of Correct Procedure at Correct Body Site Control of Concentrated Electrolyte Solutions Assuring Medication Accuracy at Transitions in Care Avoiding Catheter and Tubing Mis-connections Single Use of Injection Devices Improved Hand Hygiene to Prevent Health Care Associated Infections Definition of Solution:  Definition of Solution Any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care. Template for Solutions:  Template for Solutions Statement of Problem and Impact Associated Issues Suggested Actions Looking Forward Strength of Evidence Applicability Engaging Patients and Families Potential Barriers Risks for Unintended Consequences Selected References and Resources Solution #1: Look-Alike, Sound-Alike Medication Names :  Solution #1: Look-Alike, Sound-Alike Medication Names Confusing drug names is one of the most common causes of medication errors and is of concern worldwide. With tens of thousands of drugs currently on the market, the potential for error due to confusing brand or generic drug names and packaging is significant.   Many drug names look or sound like other drug names. Solution #1: Look-Alike, Sound-Alike Medication Names :  Solution #1: Look-Alike, Sound-Alike Medication Names Recommendations include: Use of protocols to reduce risks, ensuring prescription legibility, or the use of preprinted orders or electronic prescribing.   Changing educational curricula Advocating changes from national and international regulatory, standard-setting, and advisory boards. Collaborating with international agencies and industries to implement key changes Looking forward, use of technologies such as CPOE, bar coding and automated dispensing devices. Solution #2: Patient Identification :  Solution #2: Patient Identification Throughout the health care industry, the ongoing problem of failure to correctly identify patients continues to result in medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. Solution #2: Patient Identification :  Solution #2: Patient Identification Recommendations include: Health care providers have a primary responsibility for checking/verifying a patient’s identity. Patient and family participation Use of at least two identifiers to verify a patient’s identity; Standardize approaches to patient identification among different facilities within a health care system. Verify a patient’s identification before any interaction or intervention Use of organizational protocols for identifying patients without identification and for distinguishing the identity of patients with the same name.  Looking forward, use of automated systems such as bar-coding and biometrics. Solution #3: Communication During Patient Hand-Overs:  Solution #3: Communication During Patient Hand-Overs Gaps in hand-over (or hand-off) communication between units, between and among care teams, and from caregivers to the patient and family, and can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. Solution #3: Communication During Patient Hand-Overs:  Solution #3: Communication During Patient Hand-Overs Recommendations for improving hand-overs include using a standardized approach to for communicating critical information; ensuring that key information is available at discharge; involving patients and families in the process of care incorporating training into the educational curricula and continuing professional development for health care professionals, and encouraging communication between organizations that are providing care to the same patient in parallel. Solution #4: Performance of Correct Procedure at Correct Body Site:  Solution #4: Performance of Correct Procedure at Correct Body Site Considered preventable occurrences, these cases are infrequent, though not “rare” events and are largely the result of miscommunication and unavailable, or incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process and likely a degree of staff automaticity in the approaches to the pre-operative check routines. Solution #4: Performance of Correct Procedure at Correct Body Site:  Solution #4: Performance of Correct Procedure at Correct Body Site The recommendations to prevent these types of errors have three steps: 1) conducting a preoperative verification process, 2) marking the operative site, and 3) taking a “time out” immediately before starting the procedure. Solution #5: Control of Concentrated Electrolyte Solutions:  Solution #5: Control of Concentrated Electrolyte Solutions While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions for injection are especially dangerous. Although concentrated potassium chloride is the most common medication implicated in electrolyte administration errors, potassium phosphate concentrate and hypertonic saline also have lethal consequences if improperly administered Solution #5: Control of Concentrated Electrolyte Solutions:  Solution #5: Control of Concentrated Electrolyte Solutions Standardizing the dosing, units of measure and terminology, and preventing mix-ups of specific concentrated electrolyte solutions are addressed in the recommendations.  Looking forward, only purchase in standardized and limited drug concentrations, only purchase and utilize premixed parenteral solutions, and work with drug manufacturers and regulatory agencies to improve the safety of these solutions Solution #6: Assuring Medication Accuracy at Transitions in Care :  Solution #6: Assuring Medication Accuracy at Transitions in Care Errors are common as medications are procured, prescribed, dispensed, administered and monitored; but they occur most frequently during the prescribing and administering actions. Medication reconciliation is a process designed to prevent medication errors at patient transition points.   Solution #6: Assuring Medication Accuracy at Transitions in Care :  Solution #6: Assuring Medication Accuracy at Transitions in Care The recommendations address creating the most complete and accurate list, or Best Possible Medication History (BPMH), of all medications the patient is currently taking—also called the “home” medication list; comparing the list against the admission, transfer and/or discharge orders when writing medication orders; identifying and bringing any discrepancies to the attention of the prescribing health professional, and, if appropriate, making changes to the orders while ensuring the changes are documented; updating the list as new orders are written to reflect all of the patient’s current medications; and communicating the list to the next provider of care whenever the patient is transferred or discharged. Solution #7: Avoiding Catheter and Tubing Mis-Connections :  Solution #7: Avoiding Catheter and Tubing Mis-Connections Tubing, catheters and syringes are a fundamental aspect of daily health care provision for the delivery of medications and fluids to patients.  The design of these devices is such that it is possible to inadvertently connect the wrong syringes and tubing and then deliver medication or fluids through an unintended, and therefore, wrong route.  This is due to the multiple devices used for different routes of administration being able to connect to each other.  Solution #7: Avoiding Catheter and Tubing Mis-Connections :  Solution #7: Avoiding Catheter and Tubing Mis-Connections The best solution lies with introducing design features that prevent misconnections and prompt the user to take the correct action. Otherwise, meticulous attention to detail when administering medications and feedings (i.e. the right route of administration), and when connecting devices to patients (i.e. using the right connection/tubing), is a basic first step.   Solution #8: Single Use of Injection Devices :  Solution #8: Single Use of Injection Devices One of the biggest global concerns is the spread of Human Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) due to the reuse of injection needles.  An estimated 225,000 cases of HIV infection, 22 million HBV transmissions, and 2 million HCV transmissions occurred throughout the world in 2000 because single use needles were used by and for multiple patients. Solution #8: Single Use of Injection Devices :  Solution #8: Single Use of Injection Devices The suggested actions to address this global problem include: Prohibit the reuse of needles at health care facilities; Conduct annual training for practitioners and health care workers regarding infection control principles; Educate patients and families regarding transmission of blood borne pathogens; Implement safe waste management practices that meet the needs of individual health care organizations  Solution #9: Improved Hand Hygiene to Prevent HAI:  Solution #9: Improved Hand Hygiene to Prevent HAI It is estimated that at any one time, more than 1.4 million people worldwide are suffering from infections acquired in hospitals. Therefore, hand hygiene is a fundamental action for ensuring patient safety which should occur in a timely and effective manner in the process of care. Solution #9: Improved Hand Hygiene to Prevent HAI:  Solution #9: Improved Hand Hygiene to Prevent HAI Adopt at country, region and facility level the recommendations of the WHO Guidelines on Hand Hygiene in Health Care. Implement a multidisciplinary, multimodal strategy that makes readily accessible alcohol-based hand-rubs at the point of patient care. Provide access to a safe, continuous water supply at all taps/faucets and the necessary facilities. Provide staff education on correct hand hygiene techniques, use of promotional reminders in the workplace. Measure hand hygiene compliance through observational monitoring and feedback of performance to health care workers. Topics for Next Round of Development:  Topics for Next Round of Development Follow-up on Critical Test Results Patient Falls Healthcare Associated Infections – Central Lines Pressure Ulcers Response to the Deteriorating Patient Patient and Family Involvement Apology and Disclosure Look-alike Sound-alike Medication Packaging A Focus on Wrong Site Surgery:  A Focus on Wrong Site Surgery The Problem:  The Problem Wrong site surgery is rare—(1:100,000) Most wrong site surgery cases (64%) result in no permanent injury. There are many types of adverse events that are more frequent and more harmful. So why do we spend so much time and energy on it? Wrong Site Surgery is a Symptom:  Wrong Site Surgery is a Symptom Wrong site surgery is the poster child of sentinel events It is a symptom of the systems and culture of health care Fix wrong site surgery and we’ll fix a lot more What The Universal Protocol Is:  What The Universal Protocol Is The Universal Protocol is based on the fact that wrong site, wrong procedure, and wrong person surgery can be prevented. It is based on a consensus of experts and is intended to achieve the goal of eliminating wrong person, wrong procedure, and wrong site surgery. Development, Approval, and Endorsement::  Development, Approval, and Endorsement: Draft consensus statement (Universal Protocol) developed and circulated among participants at the First Wrong Site Surgery Summit (May 9, 2003) Universal Protocol revised based on participant feedback Posted on The Joint Commission web site for comment Over 3000 responses received; further revisions made Approved by the Board of Commissioners (July 2003) Sought endorsements of the Universal Protocol Implementation of the Universal Protocol as a requirement for accreditation (July 1, 2004) Second Wrong Site Surgery Summit (February 23, 2007) Provisions of the Universal Protocol:  Provisions of the Universal Protocol Preoperative verification process Relevant pre-op tasks completed and information is available and correct Surgical site marking Unambiguous mark, visible after prep & drape Right/left, multiple structures or levels “Time out” immediately before starting Involves entire team; active communication Fail-safe model: “No go” unless all agree Applicable to invasive procedures in all settings Wrong-site Surgeries:  Wrong-site Surgeries Types of “Wrong surgery” Cases:  Types of “Wrong surgery” Cases “Wrong Surgery” Cases by Setting:  “Wrong Surgery” Cases by Setting Solution #4: Performance of Correct Procedure at Correct Body Site:  Solution #4: Performance of Correct Procedure at Correct Body Site The recommendations to prevent these types of errors have three steps: 1) conducting a preoperative verification process, 2) marking the operative site, and 3) taking a “time out” immediately before starting the procedure. Part of “Action on Patient Safety” project Engaging Patients and Families:  Engaging Patients and Families Patients should be involved at all points in the preoperative verification process to reconfirm with the procedure staff of their understanding for the planned procedure. Patients should be involved in the surgical site marking process, whenever possible. This is a component of the Universal Protocol. Discussion of these issues should be included during the informed consent process and decisions confirmed at the time of signature for the consent. A Focus on Hand-Over Communications:  A Focus on Hand-Over Communications The Problem:  The Problem Breakdown in communication is the leading root cause of sentinel events reported to the Joint Commission between 1995 and 2006. Of 25-30,000 preventable adverse events that led to permanent disability in Australia, 11% were due to communication issues (Zinn C.  BMJ 1995; 310:1487) Solution #3: Communication During Patient Hand-Overs:  Solution #3: Communication During Patient Hand-Overs Hand-over communication relates to the process of passing patient-specific information, from: one caregiver to another one team of caregivers to another caregivers to the patient and family for the purpose of ensuring patient care continuity and safety the transfer of information from one type of health care organization to another the health care organization to the patient’s home Solution #3: Communication During Patient Hand-Overs:  Solution #3: Communication During Patient Hand-Overs Patient care hand-overs occur in many settings across the continuum of care, including: admission from primary care, physician sign-out to a covering physician, nursing change-of-shift reporting, nursing report on patient transfer between units or facilities, anesthesiology reports to post-anesthesia recovery room staff, emergency department communication with staff at a receiving facility during a patient transfer discharge of the patient to home or to another facility.  Solution #3: Communication During Patient Hand-Overs:  Solution #3: Communication During Patient Hand-Overs Strategies for improving hand-overs include: Adopt a common language for communicating critical information. Provide opportunities for providers of care to ask and resolve questions Streamline and standardize change-of-shift reporting   Read-back -- the receiver of information writes down the information and then “reads it back” to the provider of the information to obtain confirmation that it was understood correctly. Use technology such as electronic medical records, automated medication reconciliation between settings of care, and electronic patient sign-outs Utilize collaborative (multidisciplinary) rounds Involve patients and families.  Solution #3: Communication During Patient Hand-Overs:  Solution #3: Communication During Patient Hand-Overs The following strategies should be considered by WHO Member States: 1. Ensure that health care organizations put in place a standardized approach to hand-over communications between staffing shifts and between different organizational units caring for patients. Suggested elements of this approach include: Use of the SBAR (Situation, Background, Assessment, and Recommendation) technique. The allocation of sufficient time for communicating important information, and for staff to ask and respond to questions without interruptions wherever possible. Solution #3: Communication During Patient Hand-Overs:  Solution #3: Communication During Patient Hand-Overs Incorporate repeat-back and read-back steps as part of the hand-over process. Include information regarding the patient’s status, medications, treatment plans, advance directives, and any significant status changes.  Limit the exchange to information that is necessary to providing safe care to the patient. Solution #3: Communication During Patient Hand-Overs:  Solution #3: Communication During Patient Hand-Overs 2. Ensure that health care organizations put in place systems at discharge from hospital which mean that the patient and the next health care provider are given information regarding discharge diagnoses, treatment plans, medications, and test results.  3. Incorporate training on effective hand-over communications into the educational curricula and continuing professional development for health care professionals. 4. Encourage communication between organizations providing care to the same patient in parallel, for example, traditional and non-traditional providers. Engaging Patients and Families:  Engaging Patients and Families Patients must be provided information about their medical conditions and treatment care plan in a way that is understandable to the patient. Patients must be made aware of their prescribed medications, doses, and required time between medications.  Patients must be informed who the responsible provider of care is during each shift and who to contact if they have a concern about the safety or quality of care. Patients should be provided the opportunity to read their own medical record as a patient safety strategy. Engaging Patients and Families:  Engaging Patients and Families . Patients and family members must be provided with opportunities to address any medical care questions or concerns with their health care providers. Patients and family members must be informed as to the next steps in their care, so they can be available to communicate to the care providers on the next shift if necessary, and so they are prepared to be transferred from one setting to the next, or to their home. Patients and family members must be involved in decisions about their care at the level of involvement that they choose. Solutions on the Center Website:  Solutions on the Center Website For more information::  For more information: Joint Commission International Center for Patient Safety www.jcipatientsafety.org The Joint Commission International Web Site www.jointcommissioninternational.org The Joint Commission Web Site www.jointcommission.org Our e-mail addresses pangood@jointcommission.org lbotwinick@jcrinc.com

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