Diane C. Pinakiewicz

Improved Hand Hygiene to Prevent Health Care-Associated Infections

StAtement of tHe Problem And ImPAC t: It is estimated that at any one time, more than 1.4 million people worldwide are suffering from infections acquired in hospitals (1,2). Health care-associated infections (HAI) occur worldwide and affect both developed and developing countries. In developed countries, between 5% and 10% of patients acquire one or more infections and 15%–40% of patients admitted to critical care are thought to be affected (3). In resource-poor settings, rates of infection can exceed 20% (4), but available data are scanty and more research is urgently needed to assess the burden of disease in developing and transitional countries.

Assuring Medication Accuracy at Transitions in Care: Patient Safety Solutions, Volume 1, Solution 6, May 2007

STATeMenT of ProbleM And IMPAC T: Errors are common as medications are procured, prescribed, dispensed, administered, and monitored but, they occur most frequently during the prescribing and administering actions (1). The impact is significant, as medication errors harm an estimated 1.5 million people and kill several thousand each year in the United States of America (USA) , costing the nation at least US

Seventh Annual National Patient Safety Foundation Congress

3.5 billion annually (1). Other industrialized countries around the world have also found that medication adverse events are a leading cause of injury and death within their health-care systems (2,3).

Performance of Correct Procedure at Correct Body Site: Patient Safety Solutions, Volume 1, Solution 4, May 2007

The National Patient Safety Foundation (NPSF) hosted the Seventh Annual NPSF Patient Safety Congress on May 4 to 6, 2005, at the Orlando World Center Marriott Resort in Orlando, Florida. The Congress focused on critical improvements that can save lives and reduce harm every day, with a specific concentration on high-risk/high-impact areas of medical care. Leaders and organizations that have made quantum leaps in safety presented successful strategies for promoting patient safety across the continuum of the health care system. Plenary sessions and workshops highlighted the effective implementation of policies and programs that have resulted in cultural change and sustained improvement. The Congress, entitled Let’s Get On With It—Round 2, emphasized NPSF’s sense of urgency and its commitment to the following: Creating safe and supportive organizational cultures for patients and staff Moving patient safety research into practice Incorporating research findings across multiple health care settings to improve safety Identifying existing tools, best practices, and resources needed by individuals and institutions engaged in cultural change Recognizing and overcoming barriers to cultural change Employing innovations and technology to overcome these barriers This report provides a brief summary of the 4 plenary sessions, as well as the NPSF/HLA Executive Leadership Program.

National Patient Safety Foundation

A Standard Operating Protocol (SOP) is a set of instructions for implementing a defined patient care process by multiple users in a consistent and measurable manner. In the High 5s initiative, each SOP targets a specific patient safety problem, defines a standardized care process for addressing the problem, and prescribes an implementation plan that includes relevant measures and analytic procedures. These High 5s SOPs are to be implemented in a group of selected hospitals within participating countries for the purpose of demonstrating the feasibility of implementation of standardized care process across multiple hospitals and countries, as well as determining the impact of this standardization effort on the targeted patient safety problem.