Safety First...Global
Initiatives
Sharon M. Weinstein
Ann Marie T. Brooks
Sheila A. Ryan

Objectives
• Discuss role of nursing in enhancing patient
safety
• Identify nine patient safety solutions initiated by
WHO
• Identify Institute of Medicine (IOM) and Institute
for Healthcare Improvement (IHI) initiatives
• Discuss hand hygiene as a critical component to
patient safety

What Ifs
• No Needless Deaths
• No Pain or Suffering
• No Unwanted Waiting
• No Helplessness
• No Waste

Current Model
• From
– Black/white, either/or, yes/no, in/out,
good/bad:
– Polarity and duality
• To
– And/both

Saving 100K Lives
Institute for Healthcare Improvement (IHI)
• Deploy Rapid Response Teams
• Prevent Adverse Drug Events
• Improve Care for Acute MI
• Prevent Surgical Site Infection
• Prevent Central Line Infection
• Prevent Ventilator-Associated Pneumonia

Preventing Harm
• "Recognizing that health care errors affect one
in every 10 patients around the world, the
WHO's World Alliance for Patient Safety and the
Collaborating Centre have packaged nine
effective solutions to reduce such errors," said
WHO Director-General Dr Margaret Chan.
"Implementing these solutions is a way to
improve patient safety."

Nine Patient Safety Initiatives
• Look-alike, sound-alike • Control of concentrated
medication names electrolyte solutions
• Patient identification • Avoiding catheter and
• Communication during tubing misconnections
patient hand-overs • Single use of injection
• Performance of correct devices, and
procedure at correct body • Improved hand hygiene
site to prevent health care-
• Assuring medication associated infection
accuracy at transitions in
care

Leveraging Successes
• Joint Commission...a Collaborating Centre
on Patient Safety (Solutions) – 2005

Presenteeism
• From the center for work and health and journal
of occupational health nursing, a concern is the
issue of presenteeism – employees may be at
work, but due to health concerns, they are not
working optimally.
• For nurses and nursing, that may be reflected in
an increase in errors, in lack of truly being with
the patient in mind, body and spirit.

Role of presenteeism in safety
• Accidents do happen when one is not fully
engaged
• Being present in body – but not in mind
and spirit may contribute to harm
• Issue increases the cost of healthcare and
contributes to reduced productivity

The Evidence Base
• B. Allegranzi, E. Mathai, S. Bagheri Nejad, S. Dharan, W. Griffith, P.
Bonnabry, J. Storr, N. Damani, D. Pittet. Production of the WHO-
recommended alcohol-based handrub formulations in 11 different sites
worldwide. 19th European Congress of Clinical Microbiology and Infectious
Diseases; Helsinki, Finland, 16-19 May 2009.
• B. Allegranzi, S. Bagheri Nejad, H. Sax, E. Mathai, H. Richet, D. Pittet.
Successful implementation of the WHO multimodal hand hygiene
improvement strategy and tools: a survey of 230 hospitals worldwide 19th
European Congress of Clinical Microbiology and Infectious Diseases;
Helsinki, Finland, 16-19 May 2009.

Rapid Response Teams
• 3 systemic issues contributing to mortality variability:
(400% across US hospitals)
– failure to plan,
– failure to communicate;
– failure to recognize deteriorating patient condition
and rescue.
– 70% of patients show evidence of respiratory
deterioration 8 hours before arrest; 66% show
abnormal signs/symptoms within 6 hours of arrest
and MDs notified in 25% cases.

Results
• Better outcomes, less deaths
• Improved relationships;
• Improved satisfaction with RNs, MDs,
patients
• Improved nursing retention
• Financial benefits

Adverse Drug Events (ADE)
• A leading cause of injury to patients
• Poor communication of medical information at transition
points results in 50% med errors and 20% ADEs;
• Multidisciplinary check of med orders resulted in 42%
change in orders;
• 30% variation of med orders to information from patients,
parents, labels;
• An accurate and up-to-date medication list is
essential.

Summary
• Improving quality is about looking beyond
what you do and comparing the way you
work with other approaches
• Lessons learned from systems worldwide

Questions
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