The document describes the High 5s Initiative, a project aimed at reducing common patient safety issues in hospitals across multiple countries. It does this through developing standardized operating protocols for issues like surgical site identification and medication reconciliation. Hospitals that implement the protocols provide data to evaluate their impact on reducing errors and harm over 5 years. The initiative also creates an international learning community for hospitals to share best practices. Initial participating countries include Australia, Canada, Germany, Netherlands, New Zealand, UK, and US. The long term vision is for leading hospitals worldwide to learn from each other's experiences in implementing clinical safety standards.

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

2. Putting Safety on the World's
Agenda

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. 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. 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. 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. 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. Initial Participating Countries
Australia
Canada
Germany
Netherlands
New Zealand
United Kingdom
United States

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. 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. 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. Correct Site Surgery and
Safe Surgery Saves Lives Checklist

13. Concentrated Medicines
The problem:
Concentrated injectable medicines can be
fatal if not handled properly.

14. Concentrated Medicines

15. Concentrated Medicines
• Data from UK
NRLS
• High frequency,
variable harm
• Highest no. of
reported
incidents in
preparation and
administration

16. Medication Reconciliation
The problem:
Inaccurate or incomplete patient
medication information at transitions in
care can lead to harmful medication
errors.

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. 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. 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. Medication Reconciliation
- Unintentional discrepancies
Prescriber unintentionally changed, added or
omitted a medication the patient was taking
prior to admission

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. 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. Levels of Accountability
• Collaborating Center
• Lead Technical Agency (LTA)
• Hospital

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