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.