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Improving patient safety by focusing on key solutions

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VOL: 103, ISSUE: 20, PAGE NO: 21

The Collaborating Centre for Patient Safety Solutions at the World Health Organization (WHO) has this month launched nine solutions to reduce healthcare-related harm, which affects millions of patients worldwide (WHO et al, 2007).

The Collaborating Centre for Patient Safety Solutions at the World Health Organization (WHO) has this month launched nine solutions to reduce healthcare-related harm, which affects millions of patients worldwide (WHO et al, 2007).

The WHO initiative identified widespread problems and some promising solutions, and vetted them through an extensive review process that garnered feedback from healthcare providers, practitioners and other experts from more than 100 countries. The National Patient Safety Agency in the UK has been involved in the identification of these solutions (NPSA, 2007) and has endorsed them as a means of reducing risk for patients worldwide. The nine solutions cover a wide range of areas (see box, p22).

The patient safety solution on medication during transitions explains that errors are common as medications are procured, prescribed, dispensed, administered and monitored but they 'occur most frequently during the prescribing and administering actions'. It states that adverse events involving medication are a leading cause of injury and death within the healthcare system (National Audit Office, 2005).

This solution outlines the process of 'medication reconciliation', which is designed to prevent errors at patient transition points. It includes creating the most complete and accurate list possible of all medications the patient is currently taking (also called the 'home' medication list); comparing the list against admission, transfer and/or discharge orders when writing medication orders; updating the list as new orders are written; and communicating the list to the next care provider and providing the list to the patient at discharge.

The solution suggests three core strategies for improving medication safety during transitions. The first recommends that healthcare organisations put in place standardised systems to collect and document information about all current medications for each patient, and provide this list to caregivers at each care transition point: admission, transfer, discharge and outpatient visit. The solution outlines the suggested information to be collected, including prescription and non-prescription medications; dose, frequency, route and timing of last dose, as appropriate; and the sources of the patient's medications.

The second strategy makes a range of recommendations, including:

- The patient's current medication list should be displayed in a consistent, highly visible location, such as the patient's chart;

- The 'home' medication list should be used as a reference when ordering medications at the time of treatment in a clinic or emergency unit or on admission to an inpatient service;

- The reconciliation of medications - comparison of the patient's medication list with the medications being ordered to identify omissions, duplications and inconsistencies between the medications and clinical conditions, dosing errors and potential interactions - should be carried out within specified time frames;

- There should be a process for updating the list as new orders are written, to reflect all of the patient's current medications;

- There should also be a process for ensuring that, at discharge, the list is updated to include all medications the patient will be taking following discharge, including new and continuing medications, and previously discontinued medications that are to be resumed. The list should be communicated to the next providers of care and provided to the patient as part of discharge instructions.

The third strategy focuses on training in medication reconciliation for healthcare professionals. The document adds that to be optimally effective, the medication reconciliation process must involve patients and their families.

Tubing and catheter misconnections can lead to wrong route medication errors and result in serious injury or death. In the UK between 1997 and 2004 there were four reports of harm or near misses following wrong route errors when oral liquid medicines, feeds and flushes were administered intravenously, and there were three reports of death from such errors between 2001 and 2004 (Smith, 2004). A review of reported incidents between 1 January 2005 to 31 May 2006 in the UK National Reporting and Learning System identified 32 in which oral liquid medicines were administered by the IV route; seven incidents in which epidural medication was administered by the IV route; and six incidents in which IV medication was administered via the epidural route (WHO et al, 2007).

In the first of three strategies, the patient safety solution makes several recommendations for healthcare organisations and staff, including:

- Emphasise to non-clinical staff, patients and families that devices should never be connected or disconnected by them;

- High-risk catheters should be labelled (for example 'arterial', 'epidural', 'intrathecal'). For these applications the use of catheters with injection ports should be avoided;

- Practitioners should trace all lines from their origin to the connection port to verify attachments before making any connections or reconnections, or administering medications, solutions or other products;

- A standardised line reconciliation process should be included as part of handover communications. This should involve rechecking tubing connections and tracing all patient tubes and catheters to their sources on the patient's arrival in a new setting or service and at staff shift changes;

- The use of standard Luer-connection syringes to administer oral medications or enteric feedings should be barred.

The second and third strategies are concerned with training for healthcare workers on hazards, and promoting the purchasing of tubes and catheters that are designed to enhance safety and prevent misconnections with other devices or tubes.

Concentrated potassium chloride has been identified as a high-risk medication (NPSA, 2002). The document points out that while all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions for injection are 'especially dangerous'. It adds that reports of death and serious injury/disability related to the inappropriate administration of these drugs have been 'continuous and dramatic'.

WHO recommendations for healthcare organisations and staff when dealing with concentrated electrolyte solutions include the following:

- Potassium chloride should be treated as a controlled substance;

- Ideally, concentrated electrolyte solutions should be removed from all nursing units, and they should be stored only in specialised pharmacy preparation areas or in a locked area. If potassium vials are stored in a special patient care area they must each be labelled with a visible fluorescent warning label stating 'Must be diluted';

- When a pharmacist or pharmacy preparation area is not available for storage and preparation, only a trained and qualified person (such as a nurse, doctor or pharmacy technician) should be allowed to prepare these solutions;

- The prepared solution should be clearly labelled with a 'high-risk warning' label;

- It is advisable to use an infusion pump to administer concentrated solutions. If this equipment is not available, other infusion devices (such as buretrol administration tubing) may be considered for use but infusions of concentrated solutions must be monitored frequently.

The safety solutions cover the following nine areas:

- Medication names that look and sound alike;

- Patient identification;

- Improving communication during patient handovers;

- Performance of correct procedure at correct body site;

- The control of concentrated electrolyte solutions;

- Assuring medication accuracy at transitions in care;

- Avoiding catheter and tubing misconnections;

- Single use of injection devices;

- Improving hand hygiene to prevent healthcare-associated infection.

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