High 5s Project for Patient Safety:
What is the Role for IHF?
In support of the work of WHO Patient Safety Programme
Karen H. Timmons
President and Chief Executive Officer
Joint Commission International
International Hospital Federation Leadership Summit Healthcare
2 June 2010
http://www.high5s.org
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Introduction to High 5s Project
• Launched in 2007 by the World Health
Organization (WHO) to address concerns of
patient safety around the world
• A global patient safety collaboration of:
o 8 countries
o WHO Collaborating Centre for Patient Safety
Solutions
o WHO Patient Safety Programme
o Other agencies
http://www.high5s.org
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High 5s
Derives its name
from the original
intent to reduce the
frequency of:
5 problems
5 countries
5 years
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High 5s Mission
The Mission of the High 5s Project is to
facilitate implementation and evaluation
of standardized patient safety solutions:
o Within a global learning community
o To achieve measurable, significant, and
sustainable reductions in high-risk
patient safety problems
http://www.high5s.org
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Contributions of Members
• WHO Patient Safety: Policy dialogue, technical,
advocacy, country engagement
• WHO Collaborating Centre: Coordinate activities,
organise meetings, develop SOPs and evaluation
framework, establish learning communities, undertake
analyses
• Countries: Coordinate activities, develop SOPs,
recruit and support hospitals, implement and evaluate,
support data collection
• Supported by:
o Participating countries (national)
o WHO, WHO CC, U.S. Agency for Healthcare Research
and Quality, Commonwealth Fund (global)
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High 5s Project Design
http://www.high5s.org
The Standardization Challenge
• Within one country
• Across participating
countries
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Major Components of the Project
• Implementation of Standard Operating
Protocols
• Impact Evaluation Strategy
• Data collection, reporting, and analysis
• Collaborative Learning Community
• Project report
http://www.high5s.org
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WHO Collaborating Centre for
Patient Safety Solutions
 Developed Nine Patient Safety Solutions
about
the Centrebetween
 High 5sFacts
Project
Collaboration
the Centre and WHO Patient Safety
Programme
 Offers proactive solutions for patient
safety based on empirical evidence,
hard research and best practice
 Advances the entire continuum of
patient safety
 System design and redesign
 Product safety
 Safety of services
 Environment of care
http://www.high5s.org
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World Patient Safety Programme:
Ten Action Areas
Global Patient Safety Challenges :
1. Clean Care is Safer Care
2. Safe Surgery Saves Lives
Solutions to
improve patient
safety
High 5s
Patients for
Patient Safety
Research for
Patient Safety
International
Classification for
Patient Safety (ICPS)
Reporting & Learning
Catalyse
countries’ action
to achieve
safety of care
Technology for Patient
Safety
Knowledge
Management
Special projects:
- Education
- Radiotherapy
- Rewarding excellence
- When things go wrong
- Vincristine sulphate
http://www.high5s.org
Solutions for Patient Safety
http://www.high5s.org
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Definition
A Patient Safety Solution is any system
design or intervention that has demonstrated
the ability to prevent or mitigate patient harm
stemming from the processes of health care.
http://www.high5s.org
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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
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use of preprinted orders or electronic prescribing.
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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
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distinguishing the identity of patients withhttp://www.high5s.org
the same name.
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
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process.
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
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procedure to confirm patient identity, procedure,
and operative site. 16
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. http://www.high5s.org 17
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
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patient is transferred or discharged.
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
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(i.e., using the right connection/tubing).
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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
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blood borne pathogens; and safe needle http://www.high5s.org
disposal practices.
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 address the promotion of hand
hygiene adherence as a health care facility priority, requiring
leadership and administrative support and financial resources, as well
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as adopting the WHO Guidelines on Hand Hygiene
in Health Care. 21
The Standardized Project Elements
SOPs
• The critical steps
Evaluation Plan
• Performance measures
• Event analysis approach
• On-site evaluation of SOP implementation
• Culture survey
http://www.high5s.org
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Standard Operating Protocol
Defined
A Standard Operating Protocol (SOP) is a set
of instructions for implementing a defined
process in a consistent and measurable
manner by multiple users.
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Correct Site Surgery
Problem: Wrong site, wrong procedure, wrong person
surgery
Scope of SOP: All cases performed in the in-patient
operating rooms
Solution:
• Extended preoperative verification process
• Surgical site marking
• Final “time out” before incision
http://www.high5s.org
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Relationship between the Correct Site Surgery
SOP and the WHO Surgical Safety Checklist
Correct site surgery SOP
Surgical Safety Checklist
• Focus on correct person,
procedure, site
• Focus on all major surgical
risks
• Seeks uniform compliance
with standardized protocol
• Permits modification of
process per local practice
• Includes comprehensive preop verification process
• Limited (day-of-surgery)
pre-op check
• Does not include “Sign-out”
• Includes “Sign-out”
• Available only to High 5s’
participating hospitals
• Available to all hospitals
wishing to use it
Where the initiatives overlap, the expectations are
consistent. Both can be implemented without conflict.
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Relationship between the SOP and the WHO
Checklist
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Medication Reconciliation
Problem: Miscommunications about patient
medications among caregivers
Scope of SOP: Patients ≥ 65 admitted through the
Emergency Department to in-patient units
Solution:
• “Best possible medication history” on admission
• Compare with admission orders
• Reconcile discrepancies
• Repeat process at all patient care transitions
across the care continuum
http://www.high5s.org
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Concentrated Injectable
Medicines
Problem: Inadvertent injection of undiluted concentrated
medicines
Scope of SOP:
• Concentrated potassium chloride solution
• Sodium heparin >1000 units/milliliter
• Injectable morphine preparations
Solution:
• Minimize storage/preparation of concentrates on clinical
units
• Encourage ready-to-use products
• Standardize procedure if concentrated medicines must be
used on clinical units
http://www.high5s.org
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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 an Event Analysis
Framework, including the identification and
use of Protocol-specific trigger events
• Conduct baseline and periodic organization
culture surveys
http://www.high5s.org
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SOP Implementation Evaluation
• Determine whether an SOP can be implemented
as it was designed to be implemented
• Determine whether the SOPs appear to be
effective in preventing the targeted adverse events
• Determine the potential portability of the SOPs
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Project Challenges
• Standardization across diverse countries
• Language barriers
• Competition with existing in-country project
priorities
• Concerns about control of project results
• Project Launch
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Roles and Responsibilities of
Participating Hospitals
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Participating Hospital Leadership
• Oversee implementation of the SOP selected by the LTA by
ensuring all defined responsibilities are carried out in a
timely and effective manner
• Continuously work to create and sustain an organizational
culture of safety
• Enable implementation of the SOP within the established
work environment
• Encourage appropriate clinical leaders to be overt
champions for the High 5s Project
• Identify opportunities to pursue hospital-specific projects
that build upon the basic goal of the High 5s initiative.
http://www.high5s.org
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Involvement in SOP
Implementation
• Ensure adequate resources are available and dedicated to
implementing SOP
• Charge an SOP team with carrying out implementation, use
of High 5s information management system, and effective
communication between the participating hospital and the
LTA
• Periodically meet with the implementation team to review
progress and adherence to the SOP implementation and
evaluation strategies
• Regularly monitor data and progress reports from SOP
implementation team
http://www.high5s.org
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Communication
• Promote organization’s decision to participate in the High 5s
Project
• Internally and externally publicize that the organization is
part of a select few in the country participating in this
groundbreaking international patient safety initiative
• Keep the Board, staff, other key constituencies informed
about the project and its progress
• Publicly acknowledge successes related to the High 5s
Project and staff’s contribution
• Provide regular feedback regarding the progress of SOP
implementation to all participating hospital leaders and staff
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Information Management System
Ensure technical support is available to its staff
involved in:
• Use of the High 5s Information Management
System
• Maintenance of participating hospital demographic
data
• Design and use of the mechanism designed by the
http://www.high5s.org
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Participating Hospitals
Determine scope of hospital implementation,
including:
• Selection of SOP(s) to be implemented
• Determination of the number of participating
units
• Selection of units to implement the specific
SOP(s)
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Participating Hospitals (cont’d)
Implementation of the Project Plan as set forth in the SOP,
including
• Selection of members of the implementation team, including
identification of the team leader and the Project champion
• Implementation of the Project Plan as set forth in the SOP
and evaluation plan
• Collection and submission of data to the LTA or direct entry
of the data into the High 5s Information Management
System
• Conduct of event analyses
http://www.high5s.org
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IMS: Wiki platform
http://www.high5s.org
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