Nueve soluciones para la seguridad del paciente, Organización Mundial de la Salud

La Organización Mundial de la Salud (OMS) trabaja desde el año pasado en "Nueve soluciones para la seguridad del paciente" a fin de ayudar a reducir el tributo de daños relacionados con la atención sanitaria que pagan millones de pacientes en todo el mundo. Las soluciones han sido formuladas por el Centro Colaborador de la OMS sobre (Soluciones para) la Seguridad del Paciente.

En los países desarrollados, se estima que hasta uno de cada 10 pacientes hospitalizados sufren daños de resultas de la atención recibida, y en el mundo en desarrollo la cifra es probablemente mucho mayor. Lo más importante en materia de seguridad de los pacientes es conseguir conocer la manera de evitar que éstos sufran daños durante el tratamiento y la atención. Las nueve soluciones concebidas se basan en intervenciones y acciones que han reducido los problemas relacionados con la seguridad del paciente en algunos países, y se difunden ahora de manera accesible para que los Estados Miembros de la OMS puedan usarlas y adaptarlas a fin de reformular los procedimientos de asistencia al enfermo y hacerlos más seguros.

Las soluciones guardan relación con los siguientes conceptos: medicamentos de aspecto o nombre parecidos; identificación de pacientes; comunicación durante el traspaso de pacientes; realización del procedimiento correcto en el lugar del cuerpo correcto; control de las soluciones concentradas de electrólitos; asegurar la precisión de la medicación en las transiciones asistenciales; evitar los errores de conexión de catéteres y tubos; usar una sola vez los dispositivos de inyección; y mejorar la higiene de las manos para prevenir las infecciones asociadas a la atención de salud. Básicamente estas soluciones tienen por objeto ayudar a reformular la asistencia a los enfermos y evitar errores humanos perjudiciales para los pacientes.

"Reconociendo que los fallos de la atención sanitaria afectan a uno de cada 10 enfermos en todo el mundo, la Alianza Mundial para la Seguridad del Paciente y el Centro Colaborador han combinado nueve soluciones eficaces para reducir esos errores", ha explicado la Directora General de la OMS, la Dra. Margaret Chan. "Aplicar esas soluciones es una manera de mejorar la seguridad del paciente."

Sir Liam Donaldson, Presidente de la Alianza y Director General de Salud de Inglaterra, ha manifestado que: "En todo el mundo, los sistemas de salud reconocen hoy día que la seguridad del paciente es una cuestión prioritaria. El programa de trabajo de Soluciones para la Seguridad del Paciente aborda varias áreas cruciales de riesgo para los pacientes. Las medidas claras y concisas propuestas en las nueve soluciones han demostrado ser de gran utilidad para reducir las cifras inaceptablemente altas de lesiones iatrogénicas observadas en todo el mundo".

Las Soluciones para la Seguridad del Paciente, un programa central de la Alianza Mundial para la Seguridad del Paciente, de la OMS, señala a la atención la seguridad del paciente y las prácticas óptimas para reducir los riesgos a que se ven expuestos. El programa intenta asegurar que las intervenciones y medidas que hayan resuelto problemas relacionados con la seguridad del paciente en algún lugar del mundo se difundan ampliamente de manera accesible e inteligible para todos. La Joint Commission on Accreditation of Healthcare Organizations y la Joint Commission International fueron designadas oficialmente para desempeñar conjuntamente la función de Centro Colaborador de la OMS sobre (Soluciones para) la Seguridad del Paciente en 2005.

En los 12 últimos meses, el citado Centro Colaborador de la OMS ha reunido a más de 50 destacados líderes y expertos de todo el mundo en ese campo para identificar y adaptar las nueve soluciones a diferentes necesidades. Se realizó un estudio sobre el terreno de las soluciones para reunir información de importantes entidades dedicadas a la seguridad del paciente, órganos de acreditación, ministerios de salud, organizaciones internacionales de profesionales de la salud y otros expertos.

"Estas soluciones ofrecen a los Estados Miembros de la OMS un nuevo e importante recurso para ayudar a sus hospitales a evitar muertes y lesiones prevenibles", ha señalado Dennis S. O'Leary, M.D., Presidente de The Joint Commission. "Todos los países afrontan hoy tanto la oportunidad como el reto de traducir esas soluciones en acciones concretas que efectivamente salven vidas".
Nota de la Redacción

Las Soluciones para la Seguridad del Paciente se centran en los siguientes aspectos:

1. * Medicamentos de aspecto o nombre parecidos
2. * Identificación de pacientes
3. * Comunicación durante el traspaso de pacientes
4. * Realización del procedimiento correcto en el lugar del cuerpo correcto
5. * Control de las soluciones concentradas de electrólitos
6. * Asegurar la precisión de la medicación en las transiciones asistenciales
7. * Evitar los errores de conexión de catéteres y tubos
8. * Usar una sola vez los dispositivos de inyección
9. * Mejorar la higiene de las manos para prevenir las infecciones asociadas a la atención de salud

Organización Mundial de la Salud, leer nota completa en castellano

En ingles

WHO Collaborating Centre for Patient Safety Releases
Nine Life-Saving Patient Safety Solutions

Nine solutions to prevent health care errors that harm millions of people daily throughout the world were unveiled today by the World Health Organization's (WHO) Collaborating Centre for Patient Safety Solutions.  The nine Patient Safety Solutions are available for use by WHO Member States.

The Patient Safety Solutions address the issues of look-alike, sound-alike medication names; correct patient identification; hand-over communications; correct procedure at the correct body site; control of concentrated electrolyte solutions; medication accuracy; catheter and tubing mis-connections; needle reuse and injection device safety; and hand hygiene.  The basic purpose of the solutions is to guide the re-design of care processes to prevent inevitable human errors from actually reaching patients.

In 2005, WHO designated The Joint Commission and Joint Commission International as its Collaborating Centre on Patient Safety Solutions.  The Joint Commission International Center for Patient Safety operationalized this effort by identifying widespread problems and challenges to safe care, identifying promising solutions, and vetting them through an extensive field review process that garnered feedback from health care providers, practitioners, and other experts from more than 100 countries.

"Patient safety is now recognized as a priority by health systems around the world," says Sir Liam Donaldson, chair of the Alliance, chief medical officer for England, and chief medical adviser for the Government of the United Kingdom of Great Britain and Northern Ireland.  "The Patient Safety Solutions program of work is addressing several vital areas of risk to patients.  Clear and succinct actions contained in the nine solutions have proved to be useful in reducing the unacceptably high numbers of medical injuries around the world."

"These solutions offer to WHO Member States a major new resource to assist their hospitals in avoiding preventable deaths and injuries," says Dennis S. O'Leary, M.D., president, The Joint Commission.  "Countries around the world now face both the opportunity and the challenge to translate these solutions into tangible actions that actually save lives."

"These Patient Safety Solutions were designed through a truly international collaborative effort, and represent what has been learned internationally about where, how and why certain adverse events occur," says Karen H. Timmons, president and chief executive officer, Joint Commission International.  "A critical component of their development has involved inclusion of input from patients and their families who have experienced preventable harm."

The individual Patient Safety Solutions identify the following challenges and strategies:

1. * 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.  The recommendations focus on using protocols to reduce risks and ensuring prescription legibility or the use of preprinted orders or electronic prescribing.
2. * 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. The recommendations place emphasis on methods for verifying patient identity, including patient involvement in this process; standardization of identification methods across hospitals in a health care system; and patient participation in this confirmation; and use of protocols for distinguishing the identity of patients with the same name.
3. * 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. The recommendations for improving patient hand-overs include using protocols for communicating critical information; providing opportunities for practitioners to ask and resolve questions during the hand-over; and involving patients and families in the hand-over process.
4. * 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. The recommendations to prevent these types of errors rely on the conduct of a preoperative verification process; marking of the operative site by the practitioner who will do the procedure; and having the team involved in the procedure take a "time out" immediately before starting the procedure to confirm patient identity, procedure, and operative site.
5. * 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. The recommendations address standardization of the dosing, units of measure and terminology; and prevention of mix-ups of specific concentrated electrolyte solutions.
6. * 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.The recommendations address creation of the most complete and accurate list of all medications the patient is currently taking-also called the "home" medication list; comparison of the list against the admission, transfer and/or discharge orders when writing medication orders; and communication of the list to the next provider of care whenever the patient is transferred or discharged.
7. * 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. The recommendations address the need for meticulous attention to detail when administering medications and feedings (i.e., the right route of administration), and when connecting devices to patients (i.e., using the right connection/tubing).
8. * 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. The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of blood borne pathogens; and safe needle disposal practices.
9. * Improved Hand Hygiene to Prevent Health Care-Associated Infection (HAI) - 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 recommendations encourage the implementation of strategies that make alcohol-based hand-rubs readily available at points of patient care; access to a safe, continuous water supply at all taps/faucets; staff education on correct hand hygiene techniques; use of hand hygiene reminders in the workplace; and measurement of hand hygiene compliance through observational monitoring and other techniques.

The Patient Safety Solutions were developed with the assistance of an International Steering Committee of patient safety experts and patient representatives, as well as Regional Advisory Councils in Europe, the Middle East, and the Asia-Pacific region.  A major international field review of the proposed solutions was also conducted to gather feedback from leading patient safety entities, accrediting bodies, ministries of health, international health professional organizations and practitioners, patients, and other experts.