WHO Collaborating Centre for Patient Safety Releases Nine Life-Saving Patient Safety Solutions
WASHINGTON, May 2 -- Nine solutions to prevent health care errors that harm millions of people daily throughout the world were unveiled today by the World Health Organization's (WHO) Collaborating Centre for Patient Safety Solutions. The nine Patient Safety Solutions are available for use by WHO Member States.
The Patient Safety Solutions address the issues of look-alike, sound-alike medication names; correct patient identification; hand-over communications; correct procedure at the correct body site; control of concentrated electrolyte solutions; medication accuracy; catheter and tubing mis- connections; needle reuse and injection device safety; and hand hygiene. The basic purpose of the solutions is to guide the re-design of care processes to prevent inevitable human errors from actually reaching patients.
In 2005, WHO designated The Joint Commission and Joint Commission International as its Collaborating Centre on Patient Safety Solutions. The Joint Commission International Center for Patient Safety operationalized this effort by identifying widespread problems and challenges to safe care, identifying promising solutions, and vetting them through an extensive field review process that garnered feedback from health care providers, practitioners, and other experts from more than 100 countries.
"Patient safety is now recognized as a priority by health systems around the world," says Sir Liam Donaldson, chair of the Alliance, chief medical officer for England, and chief medical adviser for the Government of the United Kingdom of Great Britain and Northern Ireland. "The Patient Safety Solutions program of work is addressing several vital areas of risk to patients. Clear and succinct actions contained in the nine solutions have proved to be useful in reducing the unacceptably high numbers of medical injuries around the world."
"These solutions offer to WHO Member States a major new resource to assist their hospitals in avoiding preventable deaths and injuries," says Dennis S. O'Leary, M.D., president, The Joint Commission. "Countries around the world now face both the opportunity and the challenge to translate these solutions into tangible actions that actually save lives."
"These Patient Safety Solutions were designed through a truly international collaborative effort, and represent what has been learned internationally about where, how and why certain adverse events occur," says Karen H. Timmons, president and chief executive officer, Joint Commission International. "A critical component of their development has involved inclusion of input from patients and their families who have experienced preventable harm."
The individual Patient Safety Solutions identify the following challenges and strategies:
-- Look-Alike, Sound-Alike Medication Names -- 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. -- Patient Identification -- 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. -- Communication During Patient Hand-Overs -- 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. -- Performance of Correct Procedure at Correct Body Site -- 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. -- Control of Concentrated Electrolyte Solutions -- 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. -- Assuring Medication Accuracy at Transitions in Care -- 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. -- Avoiding Catheter and Tubing Mis-Connections -- 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). -- 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) 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. -- Improved Hand Hygiene to Prevent Health Care-Associated Infection (HAI) -- 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 encourage the implementation of strategies that make alcohol-based hand-rubs readily available at points of patient care; access to a safe, continuous water supply at all taps/faucets; staff education on correct hand hygiene techniques; use of hand hygiene reminders in the workplace; and measurement of hand hygiene compliance through observational monitoring and other techniques.
The Patient Safety Solutions were developed with the assistance of an International Steering Committee of patient safety experts and patient representatives, as well as Regional Advisory Councils in Europe, the Middle East, and the Asia-Pacific region. A major international field review of the proposed solutions was also conducted to gather feedback from leading patient safety entities, accrediting bodies, ministries of health, international health professional organizations and practitioners, patients, and other experts.
The World Alliance for Patient Safety is a WHO programme launched in 2004. The Alliance, chaired by Sir Liam Donaldson, Chief Medical Officer of the United Kingdom, addresses 10 major action areas:
-- The Global Patient Safety Challenge will galvanize global commitment and action on a patient safety topic, which addresses a significant area of risk for all countries. In 2005-2006, the Global Patient Safety Challenge is focusing on health care-associated infection with the theme Clean Care is Safer Care. For 2007-2008, the Global Patient Safety Challenge will focus on the topic of safer surgery with the theme Safe Surgery Saves Lives. -- Patients for Patient Safety will ensure that the voice of patients is at the core of the patient safety movement worldwide. -- Reporting and learning will promote valid reporting, analytical and investigative tools and approaches that identify sources and causes of risks in ways that promote learning and preventative action. -- Taxonomy for Patient Safety will develop an internationally acceptable system for classifying patient safety information to promote more effective international learning. -- Research for patient safety will facilitate an international research agenda which supports the safer health care in all WHO member states. -- Safety Solutions will translate knowledge into practical solutions and disseminate these solutions internationally. -- Safety in Action will spread best practices for implementation of changes in organizational, team and clinical practices to improve patient safety. -- Technology and patient safety will focus on the opportunities to harness new technologies to improve patient safety. -- Care of acutely ill patients will identify key patient safety priorities for action in the care of seriously ill patients. -- Patient safety knowledge at your fingertips will work with Member States and partners to gather and share knowledge on patient safety developments globally in the form of a global report.
Joint Commission International (JCI) was established in 1997 as a division of Joint Commission Resources, Inc. (JCR), a private, not-for-profit affiliate of The Joint Commission. Through international accreditation, consultation, publications and education programs, JCI extends The Joint Commission's mission worldwide by helping to improve the quality of patient care by assisting international health care organizations, public health agencies, health ministries and others evaluate, improve and demonstrate the quality of patient care and enhance patient safety in more than 60 countries.
Members of the World Health Organization Collaborating Centre on Patient Safety Solutions International Steering Committee are: Dr. Ahmed Abdellatif, WHO Regional Office, Eastern Mediterranean Region, Egypt; James P. Bagian, MD, PE, Director, VA National Center for Patient Safety, USA; Dr. Enrique Ruelas Barajas, Subsecretario de Innovacion y Calidad, Mexico; Michael Cohen, RPh, MS, ScD, President, Institute for Safe Medication Practices, USA; Diane Cousins, RPh, Vice President, United States Pharmacopeia, USA; Charles R. Denham, MD, Chairman, Leapfrog Group Safe Practices Program, USA; Kaj Essinger, Chair, Hope, Sweden; Dr. Giorgi Gegelashvili, MP, Deputy Chairman, Georgia; Helen Glenister, Director Safer Practice, National Patient Safety Agency, United Kingdom; Carolyn Hoffman, Director of Operations, Canadian Patient Safety Institute, Canada; Dr. Diana Horvath, Chief Executive Officer, Australian Commission for Safety and Quality in Health Care, Australia; Dr. Tawfik Khoja, Executive Director, Health Ministers Council for the Gulf Cooperation, Saudi Arabia; Niek Klazinga, Health Care Quality Indicator Project, OECD Health Division, Department of Social Medicine, The Netherlands; Dr. Chien Earn LEE, Senior Director, Healthcare Performance Group, Ministry of Health, Singapore; Dr. Tebogo Kgosietsile Letlape, Immediate Past-President, The World Medical Association, Inc., South Africa; Dr. Beth Lilja, Director, Danish Society for Patient Safety, Denmark; Henri R. Manasse, Jr., PhD, ScD, Executive Vice President and CEO, American Society of Health-System Pharmacists, USA; M. Rashad Massoud, MD, MPH, Senior Vice President, Institute for Healthcare Improvement, USA; Dr. Ross McL Wilson, Director, Centre for Healthcare Improvement, Northern Sydney, Australia; Andre C. Medici, Senior Health Economist, Social Programs Division, Inter-American Development Bank, Latin America; Dr. Ali Jaffer Mohammad, Director General of Health Affairs, Ministry of Health, Sultanate of Oman; William B. Munier, MD, Acting Director, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, USA; Margaret Murphy, Ireland; Melinda L. Murphy, RN, MS, CAN, Senior Vice President, National Quality Forum, USA; Dr. Zulma Ortiz, Professor of Epidemiology, University of Buenos Aires, Argentina; Diane C. Pinakiewicz, MBA, President, National Patient Safety Foundation, USA; Didier Pittet, Director of the Infection Control Programme, Geneva's University Hospitals, Switzerland; Shmuel Reznikovich, Israeli Ministry of Health, Tel Aviv, Israel; Barbara Rudolph, Director of Leaps and Measures, Leapfrog Group, USA; Susan E. Sheridan, President, Consumers Advancing Patient Safety (CAPS), USA; Dr. LUI Siu-fai, Hong Kong Hospital Authority, Hong Kong, SAR, China; Ronni P. Solomon, JD, Executive Vice President and General Counsel, ECRI, USA; Per Gunnar Svensson, Director General, International Hospital Federation, Switzerland; Stuart Whittaker, Chief Executive Council for Health Services Accreditation for Southern Africa (COHSASA), South Africa; and Robin Youngson, MD, New Zealand EpiQaul Committee, New Zealand.