«Evaluation of the WHO Patient Safety Solutions Aides Memoir Prepared for the Patient Safety Programme of the World Health Organization Donna O. ...»
Evaluation of the WHO Patient Safety
Solutions Aides Memoir
Prepared for the Patient Safety Programme
of the World Health Organization
Donna O. Farley, PhD, MPH
August 31, 2011
Table of Contents
Table of Contents
List of Figures
List of Tables
The Inaugural Set of Patient Safety Solutions Aides Memoir
The Collaborative Network
Evaluation Aims and Approach
Questions Addressed by the Evaluation
Logic Model That Guided the Evaluation
Organization of This Report
2. Evaluation Methods
Data Collection Methods
Review of Existing Written Materials
Interviews with Key Informants
Survey of Member State Stakeholders
Power Calculations To Determine Target Survey Sample Size
Analysis of Data Collected
Description of the Development and Dissemination Processes
Analysis of Stakeholder Interview Results
Analysis of Stakeholder Survey Results
3. Findings: the Patient Safety Solutions Products
The Concept of Patient Safety Aides Memoir
Interview Results on the Solutions Concept
Value of the Product to Users
Needs and Priorities of Countries
Responsiveness of the Solutions to Users’ Priorities
The Patient Safety Solutions Development Process
The Field Review for the Patient Safety Solutions
Interview Results on Development of the Solutions
Assessment of the Evidence Base
i Interview Results on the Evidence Base for the Solutions
The Patient Safety Solutions Written Products
Interview Results on the Written Products
Highlights of Findings Regarding the Solutions Products
4. Findings: Dissemination and Impacts of The Patient Safety Solutions Aides Memoir... 35 Availability and Distribution of the Products
Placement of Patient Safety Solutions on Websites
Translations into Other Languages
Interview Results on Availability of the Solutions Products
Dissemination Strategy and Implementation
Survey Results on the Dissemination Process
Interview Results on the Dissemination Process
Awareness of the Patient Safety Solutions
Survey Results on Awareness of the Solutions
Interview Results on Awareness of the Solutions
Use of the Patient Safety Solutions
Usage Reported by the Collaborative Network
Interview Results on Use of the Solutions
Highlights of Findings Regarding Dissemination and Impact
5. Summary and Suggestions for Action
1. How effective is the concept of patient safety solutions Aide memoirs?
2. What is the quality or scientific integrity of the developed Aide memoirs solutions?......55
3. How valuable are the Aide memoirs in terms of the product?
4. How effective and usable are the following specific components of the Aide memoirs for users in each of the three groups of countries?
5. What impact have the patient safety solutions Aide memoirs had in terms of aiding Member States achieve the objectives of improving patient safety:
6. How can the concept, value, quality and impact of the product be improved?.................58
ii List of Figures
Figure 3.1 Target Audiences Identified for the Patient Safety Solutions Identified by Survey Respondents (N=809)
Figure 3.2 Clinical Care Issues Identified by Survey Respondents As One of Their Country’s Five Top Patient Safety Priorities (N=881)
Figure 3.3 System Process Issues Identified by Survey Respondents As One of Their Country’s Five Top Patient Safety Priorities (N=881)
Figure 3.4 Patient Safety Solutions Rated by Survey Respondents As Extremely Relevant to Their Countries Priorities (N=826)
Figure 4.1 Assessments by Survey Respondents About Dissemination Effectiveness and WHO Office Support for Dissemination (N=441)
Figure 4.2 Assessments by Survey Respondents About the Usefulness of the Patient Safety Solutions to Organizations’ Improvement Strategies (N=317)
Figure 4.2 Estimates by Survey Respondents About How Many Other Organizations Have Used the Solutions (N=394)
iiiiv List of Tables
Table 2.1 Methods for Collecting Data To Address Each Set of Evaluation Questions.
.............. 7 Table 2.2 Profile of Individual Interviews Conducted for the Evaluation
Table 2.3 Power Calculations Used to Determine Targeted Sample Size per WHO Region.
...... 10 Table 2.4 Distribution of Stakeholder Survey Respondents by WHO Region
Table 2.5 Distribution of Stakeholder Survey Respondents by Type of Organization.
.............. 12 Table 2.6 Distribution of Stakeholder Survey Respondents by Health-Care Role
Table 3.1 Survey Respondents Assessments Regarding Roles of the Patient Safety Solutions
Table 3.2 Target Audiences for the Patient Safety Solutions Identified by Survey Respondents, by Region
Table 3.3 Level of Priority for Patient Safety in Respondents’ Countries, by WHO Region.
.... 18 Table 3.4 Top Five Clinical Care Safety Issues in Stakeholders’ Countries, by WHO Region
Table 3.5 Top Five System Process Safety Issues in Respondents’ Countries, by WHO Region
Table 3.6 Percentages of Field Review Respondents Who Strongly Agreed that the Solution Topic Is Relevant to Health Care Services in Their Country
Table 3.7 Patient Safety Solutions Rated by Survey Respondents As Extremely Relevant to Their Countries Priorities, by Region
Table 3.8 Availability of Additional Information on Patient Safety, Reported by Survey Respondents, by Region
Table 3.9 Percentages of Field Review Respondents Providing Comments on Each Patient Safety Solution
Table 3.10 Confidence of Survey Respondents in the Scientific Integrity of the Patient Safety Solutions
Table 3.11 Usefulness of the Patient Safety Solutions Products to Survey Respondents.
.......... 31 Table 4.1 Implementation of the Dissemination Plan for the Patient Safety Solutions............... 39 Table 4.2 Reported Patient Safety Solutions Hits on the Collaborating Centre Website, May 2007-July 2008
Table 4.3 Methods of Dissemination of the Patient Safety Solutions, As Reported by Survey Respondents for Their Countries
v Table 4.4 Awareness of the Patient Safety Solutions Reported by Survey Respondents, by Region
Table 4.5 How Survey Respondents First Became Aware of the Patient Safety Solutions.
....... 45 Table 4.6 Reported Use of the Patient Safety Solutions by Countries and Regions
Table 4.7 Uses and Adaptations of the Patient Safety Solutions by Survey Respondents That Used Them
Table 4.8 Issues that Prevented Survey Respondents from Using the Patient Safety Solutions 49 Table 4.
9 Estimates by Survey Respondents of How Much Each Patient Safety Solution Helped Other Organizations Achieve Safety Improvements
Table 5.1 Suggestions by the Survey Respondents for Improvements to the Patient Safety Solutions
As described on the World Health Organization (WHO) patient safety website,1 ―Patient Safety Solutions Aides memoir describe ―…system designs or interventions that demonstrate the ability to prevent or mitigate patient harm stemming from the processes of health care.‖ WHO established the goal to establish a set of Patient Safety Solutions Aides memoir (hereinafter called Solutions) that were evidence-based, presented in a standard format, and described in simple terms the actions to take to address risks associated with a particular patient safety problem. Each written Solution was to present the relevant problem and characterize the strength of evidence supporting actions to address it, including potential barriers to adoption, risks of unintended consequences created by the solution, and patient and family roles in the solution. In addition, each Solution was to cite relevant references and other resources.
In 2005, the World Health Organization (WHO) designated the Joint Commission and Joint Commission International as the WHO Collaborating Centre for Patient Safety Solutions.
Working with WHO, and with guidance from an International Steering Committee, the Collaborating Centre developed the first set of nine Patient Safety Solutions.
The Inaugural Set of Patient Safety Solutions Aides Memoir In April 2007, the inaugural set of Solutions was approved by the International Steering Committee for publication and dissemination, for use by WHO Member States as of May 2007.
The Solutions were posted on the websites of both WHO and the Collaborating Centre. 2 The
following are brief descriptions of topics for the nine Solutions:
Look-Alike, Sound-Alike Medication Names. 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 Patient Identification. 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.
Communication During Patient Hand-Overs. 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.
Performance of Correct Procedure at Correct Body Site. 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.
Control of Concentrated Electrolyte Solutions. While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous.
Assuring Medication Accuracy at Transitions in Care. Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points.
Avoiding Catheter and Tubing Mis-Connections. 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.
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) because of the reuse of injection needles.
Improved Hand Hygiene to Prevent Health Care-Associated Infections. 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.
The Collaborative Network The set of Patient Safety Solutions Aides memoir was one of the first products developed by the Collaborating Centre. These Solutions were to address patient safety issues that were a shared priority of countries around the world. To guide the development work, the Collaborating Centre established and worked with a collaborative network of stakeholders. With the release of the set of nine Solutions in May 2007, WHO and the Collaborating Centre then began a dissemination process to inform stakeholders about their availability and what they contained.
The collaborative network consisted of an International Steering Committee, three Regional Advisory Councils, and three expert panels that served as technical resources to the network.
Each of these bodies met regularly and were staffed by the Collaborating Centre staff.
International Steering Committee. Experts from leading patient safety organizations around the world were asked to serve on the Steering Committee, which had the overall responsibility of selecting the priority patient safety issues to be addressed by the Solutions and guiding development of those Solutions products. With a membership of 40 individuals, the Steering Committee broadly represented countries in all six of the WHO regions.
Regional Advisory Councils. These Councils were a mechanism to obtain feedback on the work on the Solutions emanating from the Steering Committee. Their role was to communicate the specific needs of the regions—and countries within them—to be taken into consideration during the Solutions prioritization, development, and dissemination process. Three Councils were established: Asia-Pacific Council, Middle East and North Africa Council, and Europe Council.
A representative from Israel serves on the Europe Council. Although the Collaborating Centre had hoped to establish similar Councils in Africa and South America, this was not possible because of funding limitations. However, North Africa was represented on the Middle East and North Africa Council, and South America was represented on the International Steering Committee.
According to the Collaborating Centre staff, the Steering Committee sought feedback from the Regional Advisory Councils to gain the perspectives of the different regions on patient safety priorities and the Solutions products. The Councils helped drill down details of the Solutions during development, and also provided leadership in dissemination of the Solutions, once released. In addition, the Council meetings have been a source of information on how countries have been using the Solutions, by inviting Council members to do presentations on the state of patient safety in their countries and their use of the Solutions.