High 5s Project for Patient Safety: What is the Role for IHF?

1. Karen H. TimmonsPresident and Chief Executive Officer Joint Commission International International Hospital Federation Leadership Summit Healthcare2 June 2010 High 5s Project for Patient Safety: What is the Role for IHF? In support of the work of WHO Patient Safety Programme

2. 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: • 8 countries • WHO Collaborating Centre for Patient Safety Solutions • WHO Patient Safety Programme • Other agencies

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

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

5. 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: • Participating countries (national) • WHO, WHO CC, U.S. Agency for Healthcare Research and Quality, Commonwealth Fund (global)

6. High 5s Project Design

7. The Standardization Challenge • Within one country • Across participating countries

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

9. WHO Collaborating Centre for Patient Safety Solutions • 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 Facts about the Centre 9

10. World Patient Safety Programme: Ten Action Areas Global Patient Safety Challenges : 1. Clean Care is Safer Care2. Safe Surgery Saves Lives Solutions to improve patient safety High 5s Patients for Patient Safety Catalyse countries’ action to achieve safety of care Technology for Patient Safety Research for Patient Safety Knowledge Management International Classification for Patient Safety (ICPS) Special projects: - Education- Radiotherapy- Rewarding excellence- When things go wrong- Vincristine sulphate Reporting & Learning

11. Solutions for Patient Safety 11

12. 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. 12

13. 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. 13

14. 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. 14

15. 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. 15

16. 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. 16

17. 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. 17

18. 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. 18

19. 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).   19

20. 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. 20

21. 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. 21

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

23. Standard Operating Protocol Defined A Standard Operating Protocol (SOP) is a set of instructions for implementing a defined process in a consistent and measurable manner by multiple users.

24. 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

25. Correct site surgery SOP Focus on correct person, procedure, site Seeks uniform compliance with standardized protocol Includes comprehensive pre-op verification process Does not include “Sign-out” Available only to High 5s’ participating hospitals Surgical Safety Checklist Focus on all major surgical risks Permits modification of process per local practice Limited (day-of-surgery) pre-op check Includes “Sign-out” Available to all hospitals wishing to use it Relationship between the Correct Site Surgery SOP and the WHO Surgical Safety Checklist Where the initiatives overlap, the expectations are consistent. Both can be implemented without conflict.

26. Relationship between the SOP and the WHO Checklist

27. 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

28. 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

29. Evaluation Plan • Identify and apply process and outcome measures for each Protocol • Evaluate Protocol implementation and, over time, modify Protocols as appropriate • Develop and apply an Event Analysis Framework, including the identification and use of Protocol-specific trigger events • Conduct baseline and periodic organization culture surveys

30. SOP Implementation Evaluation • Determine whether an SOP can be implemented as it was designed to be implemented • Determine whether the SOPs appear to be effective in preventing the targeted adverse events • Determine the potential portability of the SOPs

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

32. Roles and Responsibilities of Participating Hospitals

33. 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.

34. 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

35. Communication • Promote organization’s decision to participate in the High 5s Project • Internally and externally publicize that the organization is part of a select few in the country participating in this groundbreaking international patient safety initiative • Keep the Board, staff, other key constituencies informed about the project and its progress • Publicly acknowledge successes related to the High 5s Project and staff’s contribution • Provide regular feedback regarding the progress of SOP implementation to all participating hospital leaders and staff

36. Information Management System Ensure technical support is available to its staff involved in: • Use of the High 5s Information Management System • Maintenance of participating hospital demographic data • Design and use of the mechanism designed by the

37. Participating Hospitals Determine scope of hospital implementation, including: • Selection of SOP(s) to be implemented • Determination of the number of participating units • Selection of units to implement the specific SOP(s)

38. Participating Hospitals (cont’d) Implementation of the Project Plan as set forth in the SOP, including • Selection of members of the implementation team, including identification of the team leader and the Project champion • Implementation of the Project Plan as set forth in the SOP and evaluation plan • Collection and submission of data to the LTA or direct entry of the data into the High 5s Information Management System • Conduct of event analyses

39. IMS: Wiki platform www.high5s.org finalised: 2009