L’initiative OMS High 5s - High 5s NewsBulletin n°2, March 2012

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Documents complémentaires La prévention des erreurs de site et de procédure en chirurgie, Bulletin trimestriel n°2, Avril 2013 ( 634,87 Ko) La prévention des erreurs de site et de procédure, Bulletin trimestriel n°1, Janvier 2013 ( 988,67 Ko) Lettre d'information High 5s France, n°2, janvier 2012 ( 855,72 Ko) Lettre d'information High 5s France, n°1, décembre 2010 ( 1,19 Mo) High 5s NewsBulletin n°3, September 2012 ( 892,26 Ko) High 5s NewsBulletin n°2, March 2012 ( 792,83 Ko) High 5s NewsBulletin n°1, July 2011 ( 651,19 Ko) Etablissements participants - Prévention des erreurs de site et de procédure en chirurgie ( 119,2 Ko) Etablissements participants - Med'Rec ( 108,45 Ko) 1rst international High5s hospitals meeting ( 22,98 Mo) Mis en ligne le 12 avr. 2013 L’initiative « High 5s Agir pour la sécurité des patients » est un projet international lancé par l’Alliance mondiale pour la sécurité du patient de l’OMS en 2006. Coordonné par le Centre Collaborateur OMS pour la sécurité des patients (Joint Commission International), ce projet réunit 8 pays : Australie, Allemagne, Pays Bas, Canada, Etats-Unis, Singapour, République de Trinité-et-Tobago, France.L’objectif général du projet High 5s est de réduire, de façon pérenne et mesurable, des problèmes majeurs liés à la sécurité des patients. Plus précisément, High 5s vise à évaluer la faisabilité et l’impact de solutions standardisées déployées au sein d’établissements volontaires dans les huit pays participants, pendant 5 ans. En France, le projet est coordonné par la Haute Autorité de santé, engagée depuis 2009, avec le soutien du Ministère de la Santé, dans deux solutions :Solution 1 : « la prévention des erreurs de site et de procédure en chirurgie » Solution 2 : « la sécurité de la prescription médicamenteuse aux points de transition du parcours de soins» La HAS s’est associée au CEPPRAL  pour l’accompagnement des établissements dans la mise en œuvre et l’évaluation de la "solution 1" et à l’OMEDIT Aquitaine  pour la "solution 2". Principales réalisations: Publications High 5s "NewsBulletin" Juillet 2011, Mars 2012 et Septembre 2012 et les lettres d'informations "High 5s France" Décembre 2010 et Janvier 2012.Mise en place de la « solution 1 », prévention des erreurs de site et de procédure en chirurgie dans 8 établissements de santéGuide de marquage du site chirurgical (en français) ou Guide to surgical site marking (en anglais)Vidéos de retour d’expérience Le time out, Centre Hospitalier Joseph Ducuing (Toulouse)Mise en œuvre Les vérifications préopératoires au CHU de NiceBulletins trimestriels Janvier 2013 et Avril 2013 Mise en place de la « solution 2 », sécurité de la prescription médicamenteuse aux points de transition du parcours de soins (Medication Reconciliation/Med'Rec) dans 8 établissements de santé.Posters des établissements de santé : 1rst international High5s hospitals meeting Documents complémentaires La prévention des erreurs de site et de procédure en chirurgie, Bulletin trimestriel n°2, Avril 2013 ( 634,87 Ko) La prévention des erreurs de site et de procédure, Bulletin trimestriel n°1, Janvier 2013 ( 988,67 Ko) Lettre d'information High 5s France, n°2, janvier 2012 ( 855,72 Ko) Lettre d'information High 5s France, n°1, décembre 2010 ( 1,19 Mo) High 5s NewsBulletin n°3, September 2012 ( 892,26 Ko) High 5s NewsBulletin n°2, March 2012 ( 792,83 Ko) High 5s NewsBulletin n°1, July 2011 ( 651,19 Ko) Etablissements participants - Prévention des erreurs de site et de procédure en chirurgie ( 119,2 Ko) Etablissements participants - Med'Rec ( 108,45 Ko) 1rst international High5s hospitals meeting ( 22,98 Mo) La prévention des erreurs de site et de procédure en chirurgie, Bulletin trimestriel n°2, Avril 2013 ( 634,87 Ko) La prévention des erreurs de site et de procédure, Bulletin trimestriel n°1, Janvier 2013 ( 988,67 Ko) Lettre d'information High 5s France, n°2, janvier 2012 ( 855,72 Ko) Lettre d'information High 5s France, n°1, décembre 2010 ( 1,19 Mo) High 5s NewsBulletin n°3, September 2012 ( 892,26 Ko) High 5s NewsBulletin n°2, March 2012 ( 792,83 Ko) High 5s NewsBulletin n°1, July 2011 ( 651,19 Ko) Etablissements participants - Prévention des erreurs de site et de procédure en chirurgie ( 119,2 Ko) Etablissements participants - Med'Rec ( 108,45 Ko) 1rst international High5s hospitals meeting ( 22,98 Mo) Mis en ligne le 12 avr. 2013

Sujets

• Page Web
• Médecine

Informations

• Publié par: haute-autorite-sante
• Nombre de lectures: 26
• Licence : En savoir +
  Paternité, pas d'utilisation commerciale, partage des conditions initiales à l'identique
• Langue: Français

Extrait

News in Brief High 5s NewsBulletin
 Trinidad & Tobago: The Steering Group
has welcomed the participation of Trinidad &
Tobago in the High 5s collaboration. In the
opening session of the Hong Kong meeting,
Ms. I. Allan from the Ministry of Health
NO 2, MARCH 2012
shared the country's intentions to join and
implement the Correct Site Surgery SOP. High5s Steering
Highlights from the meeting  At ISQua, Hong Kong, Sept. 2011:
Group meeting in
High 5s was presented at a lunchtime The Steering Group:
 Approved the two Event session, 16 Sept. to an audience of 200 at- Hong Kong
Analysis methodologies and
tendees. 5 High 5s posters by Australia, agreed that implementation By Laura Sutton
should be started after three Germany, the Netherlands, the Col-
The High 5s Steering Group months of performance
laborating Centre and WHO were pre- measure data has been meeting was held on 12 -13 Sept.
collected. For those countries sented at ISQua 2011. 2011 in Hong Kong, Twenty-four
that have already completed
three months of data individuals representing 7
collection, event analysis
countries, WHO, and the
should begin no later than
Collaborating Centre participated. January 2012.
 Agreed to clarify evaluation
issues on the SOP
The meeting was opened with implementation questionnaire
and include performance short presentations by WHO and
measure comparative data
the Collaborating Centre and
tables for each country as an  First 2012 Steering Group meeting: It
Trinidad & Tobago was welcomed appendix to the Quarterly
will take place in the Netherlands, 14-15 May. Report.
as a new country to the Project.
 Agreed that the country-The meeting will be held at the Dutch ministry
This was followed by presentations identifiable international
of Health in The Hague.
culture survey report could on implementation and progress in
 Second 2012 Steering Group meeting be circulated to the
each country. During the meeting, participating hospitals and
links with ISQua: It will take place at WHO
SOP-specific break-out sessions posted on the website.
HQ in Geneva, 17-19 October linked with  Requested that the policies
were conducted.
on authorship and ISQua’s 29th International Conference, 21-24
publications be circulated in
October http://www.isquaconference.org/ one document for review and The Group reviewed the Quarterly
approval.  19 October 2012 meeting for Hospital
Report and made recommenda- providers: A one-day forum linked with the
tions for modifications. It also
the second meeting of 2012 along
October 2012 Steering Group meeting is
approved the event analysis
with a High 5s Hospitals meeting
dedicated to a gathering of the High 5s hos-
methodologies for implementation.
on 17-19 October in Geneva at
pitals to participate in an international
The Netherlands offered to host
WHO headquarters. This meeting
meeting and discuss High 5s issues.
the next face-to-face meeting in
precedes the ISQua Conference in
 Collaborating Centre Staff changes: B.
May 2012. WHO offered to host
order to maximize re-
Tschurtz has assumed responsibility for the
sources spent on
High 5s evaluation component, taking over
travel. A summary
from Heather Sherman. Ms. Tschurtz has 15
report of the High5s
years of experience with The Joint Comm-
Steering Group
ission (TJC) in a variety of roles. Statistical
meeting is available
support will be provided by D. Morton of TJC
at
and S. Williams will continue to provide
http://www.High5s.org
technical support for the High 5s IMS. We

thank Heather for her dedication and services.

Quality Health Care Standards and against which hospitals Focus: Australian Commission on
are assessed for accreditation.
Safety and Quality in Health Care
In 2007 Australia joined the WHO High 5s project and in (ACSQHC)
By Helen Stark and Margaret Duguid, Australian Commission on February 2010 fifteen health services (comprising 24
Safety and Quality in Health Care
hospitals) from five Australian states commenced

implementing the medication reconciliation SOP (see list of

participating hospitals). ACSQHC is responsible for the
The role of ACSQHC is to lead and
conduct of all aspects of the High 5s Project in Australia.
coordinate improvements in the

safety and quality of Australian
Australia has an interesting mix of hospitals participating in healthcare. In July 2011 the
the High 5s project. Some have been conducting Med. Rec. ACSQHC became a permanent, independent statutory authority.
for several years while others are just commencing their
implementation journey. This has meant that hospitals have ACSQHC work covers the public and private healthcare
started formal implementation and collection of performance sectors, acute and primary care. The work program is
measure data at different rates and there is considerable organised around a number of key areas:
variation in the MR1 rates across the hospitals based on their  Accreditation
stage of implementation and available resources.  Clinical communications
 Falls prevention
From Sep. 2010 to Nov. 2011 MR1 rates have averaged
 Healthcare Associated Infection
between 39% and 69% with the trend showing some
 Information Strategy
improvement .All hospitals are reporting rates for unintentional
 Medication Safety
discrepancies (MR 3) and undocumented intentional
 Open Disclosure
discprancies (MR2) less than the target of 0.3.
 Patient and consumer centred care
MR1
 Patient safety in primary health care
80
 Recognising and responding to clinical deterioration
70 69
 Safety in e-health. 60
58.156.1 56.1 55.1
50.6 51.1 51.3 51.350 49.7
47.4 46.6 45.7
42.7
40 39.4
Medication Safety Program
30
The Medication Safety Program aims to improve the safety of
20
10medication usage in Australia. With an estimated 2 to 3% of
0hospital admissions related to medicines, the safe and
effective use of medicines is considered a national safety and
To assist hospitals to implement the SOP ACSQHC holds quality priority. ACSQHC focuses its efforts in five areas:
regular teleconferences with all sites, issues a newsletter and 1. Standardisations and systems improvement;
conducts two workshops each year at which hospitals report 2. Reducing practice gaps;
their implementation progress and share ideas and new 3. Continuity of medicines management (med. rec) ;
knowledge. A range of resource materials have been 4. Using technology (Safety in E-health);
developed to assist implementation of the Medication 5. Advocating medication safety and quality (by working
Reconcilation SOP. These are available on the ACSQHC with other medication safety and quality bodies).
website at: http://www.safetyandquality.gov.au/internet/safety/ Ensuring continuity of medication management through
medication reconciliation is a priority area for ACSQHC and publishing.nsf/Content/PriorityProgram-06
an accrediting activity for Australian hospitals. The key steps
of Med Rec have been incorporated into National Safety and
2010-09
2010-10
2010-11
2010-12
2011-01
2011-02
2011-03
2011-04
2011-05
2011-06
2011-07
2011-08
2011-09
2011-10
2011-11
% patients reconciled within 24 hours of admission
A recent addition includes an on-line training program Initiatives included:
introducing Med Rec and how to use the national Medication  Training nurses and junior medical staff to take a Best
Management Plan (MMP) form to record a best possible Possible Medication History (BPMH) and conduct
medication history and reconcile medicines. The most recent medication reconciliation
workshop was held in Sydney on 22 November 2011.  Introduction of an after-hours clinical pharmacy service
Hospitals were asked to prepare a poster or short  Use of additional performance measures at admission and
presentation using the theme “Innovative approaches to discharge (see further information below)
implementing the High 5s Medication Reconciliation SOP.”  Development of electronic data collection tools for
performance measures
All hospitals provided examples of innovative thinking in their
 Standardization of medication reconciliation processes
approach to implementing the medication reconciliation SOP.
across nine hospitals in a rural area health service
With participating hospitals at different stages of
 Analysis of the clinical impact of unresolved discrepancies
implementation and facing their own unique challenges, it was
 Introduction of a “Green Bag” program to encourage
useful for teams to hear about the different approaches being
ambulance officers to bring patients’ medicines into
taken.
hospital
H. Vadhat (Clinical
Team Leader), D. Astles  Use of pharmacy technicians and ward clerks to assist
(Clinical Pharmacy
with data collection for the BPMH. Manager), R.O’Doherty
(QUM Pharmacist) and  The poster presentations were judged by a panel and Russell Levy (Dep. Dir.
participat