Http:// 1 High 5s Project for Patient Safety: What is the Role for IHF? In support of the work of WHO Patient Safety Programme Karen H. Timmons

http://www.high5s.org 1

High 5s Project for Patient Safety:

What is the Role for IHF?In support of the work of WHO Patient Safety Programme

Karen H. TimmonsPresident and Chief Executive Officer

Joint Commission International

International Hospital Federation Leadership Summit Healthcare2 June 2010

http://www.high5s.org

WHO Collaborating Centre for Patient Safety Solutions

Facts about the Centre Developed Nine Patient Safety Solutions High 5s Project Collaboration between

the Centre and WHO Patient Safety Programme

Offers proactive solutions for patient safety based on empirical evidence, hard research and best practice

Advances the entire continuum of patient safety System design and redesign Product safety Safety of services Environment of care

2


World Patient Safety Programme: Ten Action Areas

Catalyse countries’ action

to achieve safety of care

Global Patient Safety Challenges : 1. Clean Care is Safer Care2. Safe Surgery Saves Lives

Patients for Patient Safety

Reporting & Learning

Solutions to improve patient

safety

Research for Patient Safety

International Classification for

Patient Safety (ICPS)

High 5s

Technology for Patient Safety

Knowledge Management

Special projects: - Education- Radiotherapy- Rewarding excellence- When things go wrong- Vincristine sulphate


Solutions for Patient Safety

4


Definition

A Patient Safety Solution is any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.

5


Confusing drug names is one of the most common causes of Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens of medication errors and is a worldwide concern. With tens of

thousands of drugs currently on the market, the potential for error thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and created by confusing brand or generic drug names and

packaging is significant. The recommendations focus on using packaging is significant. The recommendations focus on using protocols to reduce risks and ensuring prescription legibility or the protocols to reduce risks and ensuring prescription legibility or the

use of preprinted orders or electronic prescribing.use of preprinted orders or electronic prescribing. 6


The widespread and continuing failures to correctly identify patients often The widespread and continuing failures to correctly identify patients often leads to medication, transfusion and testing errors; wrong person leads to medication, transfusion and testing errors; wrong person

procedures; and the discharge of infants to the wrong families. The procedures; and the discharge of infants to the wrong families. The recommendations place emphasis on methods for verifying patient recommendations place emphasis on methods for verifying patient

identity, including patient involvement in this process; standardization of identity, including patient involvement in this process; standardization of identification methods across hospitals in a health care system; and identification methods across hospitals in a health care system; and

patient participation in this confirmation; and use of protocols for patient participation in this confirmation; and use of protocols for distinguishing the identity of patients with the same name.distinguishing the identity of patients with the same name. 7


Gaps in hand-over (or hand-off) communication between patient care Gaps in hand-over (or hand-off) communication between patient care units, and between and among care teams, can cause serious units, and between and among care teams, can cause serious

breakdowns in the continuity of care, inappropriate treatment, and breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. The recommendations for improving potential harm for the patient. The recommendations for improving

patient hand-overs include using protocols for communicating critical patient hand-overs include using protocols for communicating critical information; providing opportunities for practitioners to ask and resolve information; providing opportunities for practitioners to ask and resolve

questions during the hand-over; and involving patients and families in the questions during the hand-over; and involving patients and families in the hand-over process. hand-over process. 8


Considered totally preventable, cases of wrong procedure or wrong site surgery 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. The

recommendations to prevent these types of errors rely on the conduct of a preoperative verification process; marking of the operative site by the practitioner who will do the procedure; and having the team involved in

the procedure take a “time out” immediately before starting the procedure to confirm patient identity, procedure, and operative site. 9


While all drugs, biologics, vaccines and contrast media have a While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used defined risk profile, concentrated electrolyte solutions that are used

for injection are especially dangerous. The recommendations for injection are especially dangerous. The recommendations address standardization of the dosing, units of measure and address standardization of the dosing, units of measure and

terminology; and prevention of mix-ups of specific concentrated terminology; and prevention of mix-ups of specific concentrated electrolyte solutions. electrolyte solutions. 10


Medication errors occur most commonly at transitions. Medication Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient reconciliation is a process designed to prevent medication errors at patient

transition points. The recommendations address creation of the most transition points. The recommendations address creation of the most complete and accurate list of all medications the patient is currently taking—complete and accurate list of all medications the patient is currently taking—

also called the “home” medication list; comparison of the list against the also called the “home” medication list; comparison of the list against the admission, transfer and/or discharge orders when writing medication orders; admission, transfer and/or discharge orders when writing medication orders;

and communication of the list to the next provider of care whenever the and communication of the list to the next provider of care whenever the patient is transferred or discharged.patient is transferred or discharged. 11


The design of tubing, catheters, and syringes currently in use is The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through such that it is possible to inadvertently cause patient harm through

connecting the wrong syringes and tubing and then delivering connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. The medication or fluids through an unintended wrong route. The

recommendations address the need for meticulous attention to recommendations address the need for meticulous attention to detail when administering medications and feedings (i.e., the right detail when administering medications and feedings (i.e., the right route of administration), and when connecting devices to patients route of administration), and when connecting devices to patients

(i.e., using the right connection/tubing). (i.e., using the right connection/tubing). 12


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) because of the reuse of injection needles.

The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and

other health care workers regarding infection control principles; education of patients and families regarding transmission of blood

borne pathogens; and safe needle disposal practices. 13


It is estimated that at any point in time more than 1.4 million people worldwide are suffering from infections acquired in hospitals. Effective

hand hygiene is the primary preventive measure for avoiding this problem. The recommendations address the promotion of hand

hygiene adherence as a health care facility priority, requiring leadership and administrative support and financial resources, as well

as adopting the WHO Guidelines on Hand Hygiene in Health Care. 14


Introduction to High 5s Project

• Launched in 2007 by the World Health Organization (WHO) to address concerns of patient safety around the world

• A global patient safety collaboration of:o 8 countries o WHO Collaborating Centre for Patient Safety

Solutionso WHO Patient Safety Programme o Other agencies


High 5s

5 years

5 problems

5 countries

Derives its name from the original intent to reduce the frequency of:


High 5s Mission

The Mission of the High 5s Project is to facilitate implementation and evaluation of standardized patient safety solutions:

o Within a global learning community

o To achieve measurable, significant, and sustainable reductions in high-risk patient safety problems


Contributions of Members

• WHO Patient Safety: Policy dialogue, technical, advocacy, country engagement

• WHO Collaborating Centre: Coordinate activities, organise meetings, develop SOPs and evaluation framework, establish learning communities, undertake analyses

• Countries: Coordinate activities, develop SOPs, recruit and support hospitals, implement and evaluate, support data collection

• Supported by:o Participating countries (national)o WHO, WHO CC, U.S. Agency for Healthcare Research

and Quality, Commonwealth Fund (global)


High 5s Project Design


The Standardization Challenge

• Within one country• Across participating

countries

20


Major Components of the Project

• Implementation of Standard Operating Protocols

• Impact Evaluation Strategy

• Data collection, reporting, and analysis

• Collaborative Learning Community

• Project report


Correct Site Surgery

Problem: Wrong site, wrong procedure, wrong person surgery

Scope of SOP: All cases performed in the in-patient operating rooms

Solution:• Extended preoperative verification process• Surgical site marking• Final “time out” before incision


Medication Reconciliation

Problem: Miscommunications about patient medications among caregivers

Scope of SOP: Patients ≥ 65 admitted through the Emergency Department to in-patient units

Solution:• “Best possible medication history” on admission• Compare with admission orders• Reconcile discrepancies• Repeat process at all patient care transitions

across the care continuum


Concentrated Injectable Medicines

Problem: Inadvertent injection of undiluted concentrated medicines

Scope of SOP: • Concentrated potassium chloride solution• Sodium heparin >1000 units/milliliter• Injectable morphine preparations

Solution:• Minimize storage/preparation of concentrates on clinical

units• Encourage ready-to-use products• Standardize procedure if concentrated medicines must be

used on clinical units


The Standardized Project Elements

SOPs• The critical stepsEvaluation Plan• Performance measures• Event analysis approach• On-site evaluation of SOP implementation• Culture survey


Project Challenges

• Standardization across diverse countries • Language barriers• Competition with existing in-country project

priorities• Concerns about control of project results• Project Launch


Roles and Responsibilities of Participating Hospitals


Participating Hospital Leadership

• Oversee implementation of the SOP selected by the LTA by ensuring all defined responsibilities are carried out in a timely and effective manner

• Continuously work to create and sustain an organizational culture of safety

• Enable implementation of the SOP within the established work environment

• Encourage appropriate clinical leaders to be overt champions for the High 5s Project

• Identify opportunities to pursue hospital-specific projects that build upon the basic goal of the High 5s initiative.

28


Involvement in SOP Implementation

• Ensure adequate resources are available and dedicated to implementing SOP

• Charge an SOP team with carrying out implementation, use of High 5s information management system, and effective communication between the participating hospital and the LTA

• Periodically meet with the implementation team to review progress and adherence to the SOP implementation and evaluation strategies

• Regularly monitor data and progress reports from SOP implementation team

29


IMS: Wiki platform

www.high5s.org

finalised: 2009

Documents

Http:// 1 High 5s Project for Patient Safety: What is the Role for IHF? In support of the work of WHO Patient Safety Programme Karen H. Timmons