The High 5 S initiative


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The High 5 S initiative. Edward Kelley. IV Internacional Conference on Patient Safety (Madrid, Ministry of Health and Consumer Affairs, 2008)

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The High 5 S initiative

  1. 1. Achieving Improvement: The High 5s Initiative World Alliance for Patient Safety
  2. 2. Putting Safety on the World's Agenda
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. High 5s Project Objective • To achieve significant, sustained, and measurable reduction in the occurrence of important patient safety problems in selected volunteer hospitals over 5 years in at least 7 countries, and • Build an international learning community that fosters the sharing of knowledge and experience in implementing innovative, standardized operating protocols and evaluating their impact.
  8. 8. Initial Participating Countries Australia Canada Germany Netherlands New Zealand United Kingdom United States
  9. 9. Major Components of the Project • Standardized Operating Protocol development • Impact Evaluation Strategy • Data collection, reporting, and analysis, including event analysis • Collaborative learning community
  10. 10. 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
  11. 11. 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.
  12. 12. Correct Site Surgery and Safe Surgery Saves Lives Checklist
  13. 13. Concentrated Medicines The problem: Concentrated injectable medicines can be fatal if not handled properly.
  14. 14. Concentrated Medicines
  15. 15. Concentrated Medicines • Data from UK NRLS • High frequency, variable harm • Highest no. of reported incidents in preparation and administration
  16. 16. Medication Reconciliation The problem: Inaccurate or incomplete patient medication information at transitions in care can lead to harmful medication errors.
  17. 17. 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
  18. 18. 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.
  19. 19. 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.
  20. 20. Medication Reconciliation - Unintentional discrepancies Prescriber unintentionally changed, added or omitted a medication the patient was taking prior to admission
  21. 21. 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.
  22. 22. 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
  23. 23. Levels of Accountability • Collaborating Center • Lead Technical Agency (LTA) • Hospital
  24. 24. 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 right medications at the right dose through better medication reconciliation • World's leading hospitals are learning from each other through the High 5s community • The global community learns what works and does not work in implementing clinical safety standards
  25. 25. For more information •Contact information • Web sites Ed Kelley, WHO World Alliance for Patient Safety