WHO Collaborating Centre for Patient Safety Solutions
No adverse event should ever occur anywhere in the world if the knowledge exists to prevent it from happening. However, such knowledge is of little use if it is not put into practice. Translating knowledge into practical solutions is the ultimate foundation of the safety solutions action area of the World Alliance for Patient Safety.
The basic purpose of the solutions is to guide the re-design of care processes to prevent inevitable human errors from actually reaching patients. An individual solution will present the problem, the strength of evidence supporting the solution, potential barriers to adoption, risks of unintended consequences created by the solution, patient and family roles in the solution, and references and other resources.
Patient Safety Solutions are defined as:
"Any system design or intervention that has demonstrated the ability
to prevent or mitigate patient harm stemming from the processes of health care."
Nine Patient Safety Solutions
In April 2007, the International Steering Committee approved nine solutions for dissemination. The nine inaugural patient safety solutions are:
1. Look-Alike, Sound-Alike Medication Names (PDF)
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.
2. Patient Identification (PDF)
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.
3. Communication During Patient Hand-Overs (PDF)
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.
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.
While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous.
6. Assuring Medication Accuracy at Transitions in Care (PDF)
Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points.
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.
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.
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.
Patient Safety Solutions Translations
Solutions Development Process
An international steering committee composed of recognized leaders and experts in patient safety oversees the selection of topics and the development of solutions. The candidate solutions are prioritized based on potential impact, strength of evidence, and feasibility for adoption or adaptation in all countries. Then the highest-priority Solutions are also reviewed by Regional Advisory Groups in different areas of the world.
A major international field review of the proposed solutions is conducted to gather feedback from leading patient safety entities, accrediting bodies, ministries of health, international health professional organizations and practitioners, patients, and other experts.
In April, the International Steering Committee approved the inaugural solutions and initiated the process for developing the second round of patient safety solutions.