Dear Colleagues,
This month, we are dedicating the majority of Patient Safety Link to the newly released Patient Safety Solutions, nine approaches for eliminating health care errors that harm millions of people daily throughout the world. The Solutions were formally announced on May 2, 2007 by the World Health Organization’s (WHO) Collaborating Center for Patient Safety for immediate use by WHO-Members’ states and health care practitioners and organizations.
The basic purpose of the Solutions is to guide the redesign of care processes to prevent inevitable human errors from actually reaching patients. The Patient Safety Solutions focus on the following challenges:
- Look-Alike, Sound-Alike Medication Names: Confusing drug names is one of the most common causes of medication errors and is of concern worldwide. With tens of thousands of drugs currently on the market, the potential for error due to confusing brand or generic drug names and packaging is significant.
- Patient Identification: Throughout the health care industry, the ongoing problem of failure to correctly identify patients continues to result in medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families.
- Communication During Patient Hand-Overs: Gaps in hand-over (or hand-off) communication between units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient.
- Performance of Correct Procedure at Correct Body Site: Considered preventable occurrences, these cases 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.
- Control of Concentrated Electrolyte Solutions: While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions for injection are especially dangerous.
- Assuring Medication Accuracy at Transitions in Care: Errors are common as medications are procured, prescribed, dispensed, administered and monitored; but they occur most frequently during the prescribing and administering actions.
- Avoiding Catheter and Tubing Mis-Connections: Tubing, catheters and syringes are a fundamental aspect of daily health care provision for the delivery of medications and fluids to patients. The design of these devices is such that it is possible to inadvertently connect the wrong syringes and tubing and then deliver medication or fluids through an unintended, and therefore, wrong route.
- Single Use of Injection Devices: 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) due to the reuse of injection needles. An estimated 225,000 cases of HIV infection, 22 million HBV transmissions, and 2 million HCV transmissions occurred throughout the world in 2000 because single use needles were used by and for multiple patients.
- Improved Hand Hygiene to Prevent Health Care–Associated Infection (HAI): It is estimated that at any one time, more than 1.4 million people worldwide are suffering from infections acquired in hospitals. Therefore, hand hygiene is a fundamental action for ensuring patient safety which should occur in a timely and effective manner in the process of care.
We invite you to read more details on the Solutions—in this issue, on the WHO Web site (
click here), and on the International Center for Patient Safety (ICPS) Web site (
click here)—and, more important, get involved in making the Solutions a part of every health care organization’s patient safety regimen.
Finally, in “Updated Sentinel Event Statistics Now Available,” we have also provided a link to The Joint Commission’s most recent data on sentinel events. These data, reported to The Joint Commission from its accredited organizations, demonstrate the need of the Joint Commission and accredited health care organizations to continue to address these serious adverse events. These data also support the importance of establishing National Patient Safety Goals and focusing energies on addressing serious errors within health care organizations.
Does your organization plan to implement one or more of the solutions? Share your experiences in the Solutions in Practice section on the ICPS website here.
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Peter B. Angood, M.D., FRCS(C), FACS, FCCM
Vice President & Chief Patient Safety Officer, The Joint Commission
Co-Director, Joint Commission International Center for Patient Safety | Laura Botwinick
Co-Director
Vice President, Joint Commission Resources
Joint Commission International Center for Patient Safety |