Preventing Risks of Infections and Medication Errors (PRIME)

PRIME was designed to impart critical and fundamental skills around IV therapy initiation, medication preparation, medication administration and the maintenance of IV lines, incorporating best global practices. It comprised five sections: medication preparation; initiation of therapy; medication administration; maintenance of vascular lines; and surveillance of healthcare-acquired infections and incidence reporting. It was put together by a group of Joint Commission International (JCI) consultants; the programme also gave an overview of the JCI's patient-centred standards and healthcare organisation management standards. The training involved continuous interaction to facilitate the consistent adoption of learning approaches for all hospital stakeholders.

The programme goals were focused on two fundamental areas:

• Improving knowledge and skills on medication preparation and administration and VAD placement and maintenance; this was evaluated through interviews and observations by safety champions, who delivered the training to frontline staff
• Improvement in compliance to the PRIME programme standards, based on JCI medication error prevention and infection prevention standards, was evaluated through the feedback of programme leaders and the champions.

PRIME facilitators and course structure

The JCI's mission is to continuously improve the safety and quality of care in the international community through education, advisory services, and international accreditation and certification. JCI developed the course content.

Twenty-one tertiary hospitals in Indonesia, India, Malaysia, the Philippines, South Korea, Thailand and Vietnam volunteered to implement the PRIME programme. The programme, which had a duration of 6 months, was run between May 2019 and March 2021. Each hospital decided its own start and end dates.

Safety champions from the hospitals—mainly nursing supervisors and nursing educators—to train the frontline staff were selected.

The first step was training the safety champions. The training sessions were facilitated by clinical consultants who worked for Becton Dickinson (BD), who had been trained by JCI consultants. BD, a medical technology company, sponsored the programme. The second step involved nursing leaders training frontline staff by nursing leaders with support from JCI-certified trainers.

• PRIME programme leads at the hospitals held roles including medical/nursing director, hospital administrator, quality director, infection control head, infection control officer, infection control nurse, quality nurse and nursing supervisor. There were a minimum of three and a maximum of five leads per hospital. Their responsibilities were to interact with JCI consultants and the BD clinical consultants and share programme updates with hospital leadership. They also analysed the audit data shared by safety champions and gained an understanding of the challenges, especially in areas of non-compliance, and made suggestions on corrective and preventive actions.
• PRIME safety champions, who made up the implementation team, included intensivists, anaesthetists, infection control nurses, quality managers, nursing leaders/managers, nurse educators and pharmacists. This ensured department leaders from all clinical areas across the hospital were represented. This group was trained by JCI-certified trainers (the BD clinical consultants). The duration of training was 14 hours spread over 2 days in the hospital premises. With representation from each clinical department, trainee groups had between 20 and 52 participants. Armed with knowledge and insights on best practices, the safety champions trained (1-2 hour duration) nurses during their shifts in specific wards. This had the following schedule:
• – Week 1: Safe medication preparation practices, including aseptic technique, calculations, the five rights (the right patient, the right drug, the right time, the right dose and the right route), hazardous medication and the health professional's safety
• – Week 2: Selection and initiation of vascular delivery of medications, including intramuscular and subcutaneous injection, and processes for placing VADs
• – Week 3: Medication administration
• – Week 4: Prevention of complications, peripheral or central line-associated bloodstream infections, adverse drug events, and medication error reporting.

After undergoing training, the safety champions had to demonstrate, communicate and, to some extent, ensure staff knew the hospital leadership was committed to PRIME. This team would also conduct monthly assessments in the form of interviews to assess knowledge and compliance to bedside practices as well as monthly observations in various clinical areas using an audit tool provided in the programme toolkit. The objective of these assessments was to identify areas of non-compliance and to address them individually. It was essential to compile, tabulate and report the observations with the programme leads every month (preferably by the 10th day of the month).

Monthly, online meetings between the hospital leaders and JCI consultants were scheduled a part of the programme. Here, the leaders could share the progress, ask questions and seek expert inputs on areas for improvement. These areas were identified based on the compliance scores at monthly audits.