Safe and Sound

Medical errors still occur with a worrying frequency, yet many of them are entirely preventable. Nic Paton reports on a new initiative to develop and implement systems that will minimise medical mistakes and avoid their sometimes tragic consequences.

When John Heron was admitted to Ayr Hospital in Scotland to have his cancerous left kidney removed it should have been a straightforward enough operation. But during the procedure in 2006, surgeons mistakenly removed his healthy right kidney, leaving the formerly fit and active self-employed builder facing years of dialysis and the prospect of a further operation to treat his remaining diseased organ.

Sadly, despite the best efforts of surgeons and other healthcare professionals around the world, completely preventable errors – or adverse events – such as this remain all too common. In fact, the World Health Organization (WHO) has estimated that medical errors seriously harm one in every ten patients.

To remedy this situation, back in 2004, WHO launched The World Alliance for Patient Safety, with the aim of coordinating, disseminating and accelerating improvements in patient safety worldwide. This led, the following year, to the Joint Commission on Accreditation of Healthcare Organizations and Joint Commission International being designated as the world"s first WHO collaborating centre dedicated solely to patient safety.

This collaboration, known as the Joint Commission International Center for Patient Safety (JCICPS), resulted, in May 2007, in the publication of nine patient safety solutions tackling what were perceived to be the most urgent challenges in reducing the toll of healthcare-related harm.

At first glance the nine solutions outlined by JCICPS seem obvious, self-evident almost. Certainly, most lay people would probably feel that these solutions tackle problems that should be being addressed daily by the vast majority of healthcare institutions around the world.

Yet setting these nine solutions down has been valuable, according to Dr Peter Angood, co-director of the JCICPS, because day-to-day pressures, lack of communication and bureaucracy or any number of other problems can still lead to completely avoidable adverse incidents more often than most healthcare professionals would care to admit. The reality is that patient safety has not been properly addressed in the past, he says.

For example, it is very simple to educate people (patients, families and healthcare workers) on the importance of regular hand washing, but probably only 40–50% of healthcare workers do so, says Dr Angood.

NINE SOLUTIONS FOR SUCCESS

The solutions offered by JCIPCPS are as follows:

• Look-a-like, sound-a-like medication

  The problem: The confusing of drug names is one of the most common causes of medication errors around the world. With tens of thousands of drugs currently on the market, the potential for confusing brand or generic drug names and packaging is significant, according to the Joint Commission International Centre for Patient Safety (JCICPS).

  The solution: Focus on using protocols to reduce risks and ensure prescription legibility, use pre-printed orders or electronic prescribing.

• Patient identification

  The problem: Widespread and continuing failures to correctly identify patients often lead to medication, transfusion and testing errors, wrong-person procedures and the discharge of infants to the wrong families.

  The solution: Implement systems for verifying patient identity and involve them in this process. Standardise identification methods across hospitals in a healthcare system (and include patient participation in this confirmation). Use protocols to distinguish the identity of patients with the same name.

• Communication during patient handovers

  The problem: Gaps in handover (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 to the patient.

  The solution: Use protocols for communicating critical information. Provide opportunities for practitioners to ask and resolve questions during the handover. Involve patients and families in the handover process.

• Correct procedure at the correct body site

  The problem: The cases of wrong procedure or wrong site surgery are considered totally preventable and are largely the result of miscommunication and the unavailability or erroneousness of information. A major contributing factor to these errors is the lack of a standardised preoperative process, according to JCICPS.

  The solution: Have a clear preoperative verification process that includes the marking of the operative site by the practitioner who will do the procedure. Have the team involved in the procedure take a time-out immediately before starting the procedure to confirm patient identity, procedure and operative site.

• Concentrated electrolyte solution control

  The problem: While all drugs, biologics, vaccines and contrast media have a defined risk profile, the concentrated electrolyte solutions that are used for injection are especially dangerous.

  The solution: Standardise dosing, units of measure and terminology. Prevent mix-ups of specific concentrated electrolyte solutions.

• Medication accuracy at transitions in care

  The problem: Medication errors occur most commonly at transitions. Medication reconciliation is designed to prevent medication errors at patient transition points.

  The solution: Create the most complete and accurate list of all medications the patient is currently taking (called the home medication list). Compare this list against the admission, transfer and/or discharge orders when writing medication orders. Communicate the list to the next provider of care whenever the patient is transferred or discharged.

• Catheter and tubing misconnections

  The problem: The design of tubing, catheters and syringes currently in use is such that it is possible to inadvertently cause patient harm by connecting the wrong syringes and tubing, and then deliver medication or fluids through the wrong route, according to JCICPS.

  The solution: Pay meticulous attention to detail. When administering medications and feedings, use the correct route of administration. When connecting devices to patients, use the right connections and tubing.

• Injection control

  The problem: One of the biggest global health concerns is the spread of HIV, and hepatitis B and C, due to the reuse of injection needles.

  The solution: Prohibit the reuse of needles at healthcare facilities. Ensure there is periodic training for practitioners and other healthcare workers in infection control principles. Educate patients and families on the transmission of blood-borne pathogens. Enforce safe needle disposal practices.

• Hand hygiene

  The problem: It has been estimated that, at any given time, more than 1.4 million people worldwide are suffering from infections acquired in hospitals.

  The solution: Effective hand hygiene is the primary preventive measure for avoiding this problem, according to the JCICPS. Implement strategies that make alcohol-based hand-rubs readily available at points of patient care. Ensure access to a safe, continuous water supply at all taps. Educate staff on the correct hand hygiene techniques. Provide hand hygiene reminders in the workplace. Measure hand hygiene compliance through observational monitoring and other techniques.

PASSING ON BEST PRACTICE

Laura Botwinick, JCICPS co-director, says: "The thinking behind the JCICPS solutions is that around the world people are identifying patient safety solutions, but often they do not have a mechanism for getting that information communicated or passed around."

The US-based centre, through a network of regional advisory groups across the Middle East, Asia Pacific and Europe, overseen by an international steering committee, is able to act as a conduit for these solutions and pass on best practice, she says.

The nine solutions have been translated into numerous languages and the JCICPS is working to disseminate its activities at many levels, including, where possible, at country-wide ministry of health level.

At the other end of the scale, Botwinick adds, there is recognition that patient safety is not solely an issue for healthcare professionals. "We are developing these solutions not only with healthcare experts but with patient family representatives," she says. "That is really important. We need to be sure families and patients understand patient safety problems, too, and why adverse events occur. We need to be getting patients and families involved in a way that is not a burden or frightening to them."

Another significant step was the launch in November last year of a pilot project called High 5 between Canada, Germany, the Netherlands, New Zealand, the UK and the US. This says Botwinick, is designed to "drill down" into the nine solutions and examine practical ways in which they can be communicated and implemented on the ground in a consistent way.

OPERATING PROTOCOLS

The centrepiece of the project, which is due to go live in late summer this year, has been the creation of a series of standardised operating protocols (SOPs) to address five of the most widespread patient safety challenges. These can be used by hospitals in the participating countries over the next five years and their effect in reducing avoidable deaths and serious injuries evaluated.

The evaluation process will also look at the economic and cultural impact of the SOPs at the hospital level. The five SOPs – which inevitably echo the nine solutions – seek to:

• Promote effective management of concentrated injectable medicines
• Ensure medication accuracy at transitions in care
• Improve communications during patient care handovers
• Ensure performance of the correct procedure at the correct body site
• Promote improved hand hygiene to prevent healthcare-associated infections

The volunteer hospitals taking part in the pilot will be encouraged to share their experiences and any lessons learned with each other through an electronic learning community. It is anticipated that, as the pilot progresses, the SOPs will be refined and developed.

"It is very much still in the organisational phase," says Botwinick. "We have got the countries involved, and there have been meetings with designated representatives for the development of protocols and the evaluation of the strategy. We are now soliciting for volunteer hospitals to serve as learning laboratories, and the infrastructure is being put in place."

However, the learning does not stop there, according to Dr Angood. The second phase of the JCICPS's project has already begun with the identification and field testing of five new solutions to complement the existing nine. These solutions, while very much in draft form and under development, are: improving central line care to prevent healthcare-associated infection, recognising and responding to deteriorating patients, communicating critical test results, preventing patient falls and preventing pressure ulcers.

On top of this work, JCICPS is working to raise awareness and best practice among healthcare professionals of other potential issues when it comes to patient safety. For example, in August last year, it warned in a study that while abbreviations in healthcare may be efficient their use can come at the expense of patient safety.

"We are also making an effort to build solutions at a macro level, by looking at problems that would need input and deliberation from multiple sectors, such as packaging and medication labelling issues," adds Dr Angood.

Ultimately, it is clear that the development of the nine solutions is simply the first of many steps. What is also apparent is that, while it is unlikely that healthcare professionals will ever be able to completely eliminate tragedies such as John Heron's lost kidney, there is much that can be done, some of it very simple and some of it costing virtually nothing.

Dr Angood points out that the ongoing collation, evaluation and communication of solutions as they are used and developed on the ground means that, over time, the work of the JCICPS will become an invaluable best practice database for healthcare professionals around the world.

"We are developing a really good library and, as High 5 gets implemented, we will learn lessons there about what works in different countries with different resources," he says.