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 President and Chief Executive Officer Joint Commission International International Hospital Federation Leadership Summit Healthcare 2 June 2010

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 Care 2. 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 medication errors and is a worldwide concern. With tens of thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and packaging is significant. The recommendations focus on using protocols to reduce risks and ensuring prescription legibility or the use of preprinted orders or electronic prescribing. 6

The widespread and continuing failures to correctly identify patients often leads to medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. The recommendations place emphasis on methods for verifying patient identity, including patient involvement in this process; standardization of identification methods across hospitals in a health care system; and patient participation in this confirmation; and use of protocols for distinguishing the identity of patients with the same name. 7

Gaps in hand-over (or hand-off) communication between patient care units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. The recommendations for improving patient hand-overs include using protocols for communicating critical information; providing opportunities for practitioners to ask and resolve questions during the hand-over; and involving patients and families in the 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 defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous. The recommendations address standardization of the dosing, units of measure and terminology; and prevention of mix-ups of specific concentrated electrolyte solutions. 10

Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points. The recommendations address creation of the most complete and accurate list of all medications the patient is currently taking— also called the “home” medication list; comparison of the list against the admission, transfer and/or discharge orders when writing medication orders; and communication of the list to the next provider of care whenever the patient is transferred or discharged. 11

The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. The recommendations address the need for 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). The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. The recommendations address the need for 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). 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

15 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: o8 countries oWHO Collaborating Centre for Patient Safety Solutions oWHO Patient Safety Programme oOther agencies

16 High 5s 5 years 5 problems 5 countries Derives its name from the original intent to reduce the frequency of:

17 High 5s Mission The Mission of the High 5s Project is to facilitate implementation and evaluation of standardized patient safety solutions: oWithin a global learning community oTo achieve measurable, significant, and sustainable reductions in high-risk patient safety problems

18 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: oParticipating countries (national) oWHO, 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

21 Major Components of the Project Implementation of Standard Operating Protocols Impact Evaluation Strategy Data collection, reporting, and analysis Collaborative Learning Community Project report

22 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

23 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

24 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

25 The Standardized Project Elements SOPs The critical steps Evaluation Plan Performance measures Event analysis approach On-site evaluation of SOP implementation Culture survey

26 Project Challenges Standardization across diverse countries Language barriers Competition with existing in-country project priorities Concerns about control of project results Project Launch

27 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

30 IMS: Wiki platform finalised: 2009