New Solutions for Old Problems in Safeguarding Patient Safety

In an effort to guide the redesign of healthcare processes to prevent inevitable human errors from actually reaching patients, the World Health Organization (WHO)s Collaborating Centre for Patient Safety Solutions has introduced nine Patient Safety Solutions that address the following challenges and strategies:

1. Look-alike, sound-alike medication names: The recommendations focus on using protocols to reduce risks and ensuring prescription legibility or the use of preprinted orders or electronic prescribing.

2. Patient identification: The recommendations emphasize methods for verifying patient identity, including patient involvement in this process; standardization of identification methods across hospitals in a healthcare system; and use of protocols for distinguishing the identity of patients with the same name.

3. Communication during patient hand-overs: 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.

4. Performance of correct procedure at correct body site: 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.

5. Control of concentrated electrolyte solutions: The recommendations address standardization of the dosing, units of measure and terminology; and prevention of mix-ups of specific concentrated electrolyte solutions.

6. Assuring medication accuracy at transitions in care: 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.

7. Avoiding catheter and tubing misconnections: 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).

8. Single use of injection devices: The recommendations address the need for prohibitions on the reuse of needles at healthcare facilities; periodic training of practitioners and other healthcare workers regarding infection control principles; education of patients and families regarding transmission of bloodborne pathogens; and safe needle disposal practices.

9. Improved hand hygiene to prevent healthcare-associated infections (HAIs): 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.

These solutions remind us that, along with a healthy dose of zero tolerance, common-sense, evidence-based practice is still the best and only way to address the pervasive issue of HAIs.

Until next month, bust those bugs!

Kelly M. Pyrek 
Group Editor, Medical Division kpyrek@vpico.com