Nine Life-Saving Patient Safety Solutions from WHO
May 15th, 2007 | Published in Real Time Location Systems
Earlier this month the World Health Organization (WHO) released a list of 9 patient safety areas that can impact patient safety. (WHO calls these 9 items “solutions” but they're really not solutions until you actually implement them and apply QI (quality improvement) methods to them.) The items on the list are one's we've seen before from any number of patient safety organizations, but their heart is in the right place. Here's the list:
- 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.
Most of these “solutions” are dependent on staff awareness, training, and - dare I say it, change. But improving patient safety is much more than remembering to wash your hands and following procedures to minimize confusion and miscommunication. To really make long lasting major improvements in patient safety means changing fundamental things like the way care is delivered to minimize transfers (a major source of communications snafus and adverse events), or implementing Rapid Response Systems to identify and rescue deteriorating patients .
The real challenge is creating a cohesive patient safety strategy out of the mish mash of products and services from vendors who want to improve communications, eliminate alarm fatigue, reliably identify patients and help administer meds. Of course most of these solutions are proprietary end to end systems; yet none of them provide a complete point of care patient safety solution.
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