[indices] WHO launches Patient Safety Solutions

["Rochat Carolyn" <rochatc@nbi-kzn.org.za>]

WHO Collaborating Centre for Patient Safety Releases

Nine Life-Saving Patient Safety Solutions 

 (WASHINGTON, D.C., USA - May 2, 2007) 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.

For more information or to view the complete Patient Safety
Solutions, please access
www.jointcommissioninternational.org/solutions


Carolyn Rochat