1114 / WHO High 5s SOP for Concentrated Injectable Medicines

NETHERLANDS
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Medical devices / Equipment
Other There is no specified text here
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
 
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.
The Concentrated Injectable Medicines SOP
This SOP addresses the prevention of medication errors associated with the preparation, storage, or
administration of concentrated injectable medicines. The implementation effort focuses on the three
injectable medicines that are most frequently associated with errors resulting in death or serious patient
harm. These are:
1. concentrated potassium chloride solution;
2. sodium heparin (>1000 units/milliliter);
3. injectable morphine preparations.
Description of the Patient Safety Practice
 
This SOP seeks to prevent these errors by minimizing the storage and use of concentrated injectable
medicine products by replacing them with ready-to-administer or ready-to-use injectable products that do
not need to be diluted before use.
Where a concentrated injectable medicine must continue to be stored and prepared in a clinical area, the
risks of using this product will be managed by implementing multiple precautionary measures including
the following:
1. Minimize look-alike labeling and packaging of concentrated injectable medicines.
2. Segregate storage of concentrated injectables from other medicines.
3. Limit access to concentrated injectables to a small number of qualified staff.
4. Limit the amount of concentrated injectable drugs stored in the clinical area
5. Affix a prominent warning label to each unit of the concentrated injectable medicine.

SOP Evaluation
Evaluation of the SOP implementation and its impact on patient outcomes will include:
1. Standardized process and outcome measures addressing the management of concentrated injectable medicines and the frequency of associated adverse events to evaluate hospitals’ performance over time and in comparison with other participating hospitals and countries.
2. Detailed event analyses of specified adverse drug events if and when they occur.
3. Qualitative information obtained through direct observation at the participating hospitals and interviews of their leadership and staff members.

The results of these evaluation strategies will be used to improve the efficiency and effectiveness of a standardized approach to the management of concentrated injectable medicines and to assess the feasibility and efficacy of standardization in this context.

Attachment of relevant written information and/or photos, as appropriate
201411250330402768_WP4_109.full DEF.pdf
There is no specified text here
There is no specified text here
There is no specified text here
Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, partly
Level of implementation of reported practice
Regional or national level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation's results
16 Dutch hospitals are implementing the SOP for Concentrated Injectable Medicines. 5 out of this group also implemented the SOP for Medication Accuracy at Transitions in Care (15 Dutch hospitals took part in this SOP). SOP for CIM results will be evaluated at the end of 2014/early 2015. The SOP seeks to strengthen the implementation of a national guideline and one of the themes of the national patient safety programme. The hospitals all evaluated all CIMs in their hospital at all inpatient units.
201411250337551768_WP4_ISQUA14-1857-preview-6.pdf
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
No
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Physicians
Nurses
Pharmacists
Scientific staff / researchers
Quality manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Not known
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
There is no specified text here
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users' level of involvement
There is no specified text here
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Yes
List of sources where public information is accessible
via the WHO High 5s website: SOPs will be internationally published in 2015.
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Yes
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Public exposure
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Yes
Description of used incentives, if any.
Due to national focus on this theme 16 hospitals took part in this pilot programme.
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Erica van der Schrieck-de Loos
Country: NETHERLANDS
Organisation: CBO Dutch Institute for Healthcare Improvement
E-mail: e.vanderschrieck@cbo.nl
Phone: + 31 6 51937338
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