Achieving Improvement: The High 5s Initiative World Alliance for Patient Safety

Putting Safety on the World's Agenda

How the Alliance Works: Strategizing Patient Safety

Strengthen capacity

Build sustainable partnerships

Scale up and evaluate impact

Develop solutions

Raise awareness and understand problem

Creating Safer

Health Care

Raising awareness

Strengthen Capacity

Build sustainable partnerships

Scale up and evaluate Impact

Develop Solutions

Raise awareness and

understand problem

Creating Safer

Health Care

•Research •Reporting and Learning •Taxonomy

Adverse Event Studies- PAHO and EMRO 2007-2008

Developing solutions to problems

Strengthen Capacity

Build sustainable partnerships

Scale up and evaluate Impact

Develop Solutions

Raise awareness and understand problem

Creating Safer

Health Care

•Solutions •Technology

Scaling up and evaluating impact

Strengthen Capacity

Build sustainable partnerships

Scale up and evaluate Impact

Develop Solutions

Raise awareness and understand problem

Creating Safer

Health Care

•Global Patient Safety Challenges •Matching Michigan: Eliminating CLABSI •High 5’s

High 5s – 2009 Hospital Launch

High 5s Project Objective • To achieve significant, sustained, and

measurable reduction in the occurrence of important patient safety problems in selectedvolunteer hospitals over 5 years in at least 7countries, and

• Build an international learning community that fosters the sharing of knowledge and experiencein implementing innovative, standardized operating protocols and evaluating theirimpact.

Initial Participating Countries

Australia

Canada

Germany Netherlands

New Zealand

United Kingdom

United States

Major Components of the Project

• Standardized Operating Protocol development

• Impact Evaluation Strategy • Data collection, reporting, and analysis,

including event analysis • Collaborative learning community

High 5s Standardized Operating Protocols

• Performance of Correct Procedure at Correct Body Site (U.S.)

• Assuring Medication Accuracy at Transitions in Care (Canada)

• Managing Concentrated Injectable Medicines (U.K.)

• Communication During Patient Care Handovers (Australia) Phase II

• Improved Hand Hygiene to Prevent

Health Care-Associated Infections

Correct Site Surgery The problem:

Procedures performed on the wrong patient or at the wrong body site can be physically and psychologically devastating, are more common than generally appreciated, and are preventable.

Correct Site Surgery and Safe Surgery Saves Lives Checklist

Concentrated Medicines The problem:

Concentrated injectable medicines can be fatal if not handled properly.

Concentrated Medicines

Concentrated Medicines • Data from UK

NRLS • High frequency,

variable harm

• Highest no. of reported incidents in preparation and administration

Medication Reconciliation The problem:

Inaccurate or incomplete patient medication information at transitions in care can lead to harmful medication errors.

Medication Reconciliation in Canada

• One of six interventions introduced in the Safer Healthcare Now! SHN campaign (launched in 2005)

• Teams voluntarily submit data to the Central Measurement Team

Medication Reconciliation • Adverse drug events are a leading cause of

injury and death within healthcare systems and that communication problems between settings of care are a significant factor in their occurrence

• Up to 67% of patients’ prescription medication histories have one or more errors and chart reviews have revealed that over half of all hospital medication errors occur at the interfaces of care.

Medication Reconciliation Process

- Obtain a best possible medication history - Use that list when writing admission, transfer

and/or discharge medication orders - Compare the list against the patient’s admission,

transfer and/or discharge orders, identify and bring any discrepancies to the attention of the prescriber and, if appropriate, making changes to the orders. Any resulting changes are recorded.

Medication Reconciliation - Unintentional discrepancies

Prescriber unintentionally changed, added or omitted a medication the patient was taking prior to admission

Canadian Safer Healthcare Now! Campaign Results

Unintentional discrepancies (medication errors) have decreased from 1.2 per patient to 0.42 per patient over an 18 month period. Of the over 200 teams reporting data, 54% have reached the national goal of 0.25 unintentional discrepancies per patient.

High 5s Evaluation Plan

• Identify and apply process and outcome measures for each Protocol

• Evaluate Protocol implementation and, over time, modify Protocols as appropriate

• Develop and apply event analysis plan, including the identification and use of Protocol -specific trigger events

• Conduct baseline and periodic

organization culture surveys

Levels of Accountability

• Collaborating Center

• Lead Technical Agency (LTA)

• Hospital

Where will we be in the next five years?

A partial vision • Surgery is safer with the use of the

standard steps to ensuring safety • Harm from concentrated

medicines has been reduced through national and local campaigns

• Patients can expect the rightmedications at the right dosethrough better medicationreconciliation

• World's leading hospitals arelearning from each other throughthe High 5s community

• The global community learns what works and does not work in implementing clinical safety standards

For more information •Contact information • Web sites Ed Kelley, www.who.int/patientsafety WHO World Alliance for Patient Safety kelleye@who.int