I used to work for the World Health Organization (WHO) helping to establish its patient safety programme over 20 years ago. Last week I was invited back to attend a three day WHO meeting on behalf of Patient Safety Learning to contribute to the development of its Global Patient Safety Action Plan for 2020-2030. Heading into this event, I had several key questions at the front of my mind:
- What have we learned about patient safety in the last twenty years?
- Why does harm remain so persistent?
- What impact has the global commitment to patient safety had in reducing harm?
- What approaches to patient safety are having the most impact?
- How can we be more effective share learning for safer care?
A truly global problem
This event took place within the context of the resolution of World Health Assembly (the decision-making body of WHO which is attended by delegations from all member states) in May 2019. This WHA resolution agreed to address global patient safety in a concerted manner. The meeting last week was to take this forward by developing a Global Patient Safety Action Plan between member states and the WHO to reduce unsafe care.
In the introductory speeches the huge scale of the problem was set out:
- WHO considers that unsafe care is one of the 10 leading causes of death and disability worldwide.
- There are 134 million adverse events in hospitals in low and middle income countries, resulting in 2.6 million deaths annually.
- 1 in every 10 patients are harmed while receiving hospital care in high income countries.
In addition to the shocking human cost, it was noted that patient safety incidents also serve to erode trust in healthcare and come with a major economic penalty – with it being estimated that nearly 15% of all health expenditure is attributed to patient safety failures annually, running into a trillions of dollars each year.
Maintaining momentum
Sir Liam Donaldson (WHO Envoy for Patient Safety) outlined in his introductory comments at this event the importance of maintaining momentum from the WHA resolution to tackle the issue patient safety in a global movement for change. He talked about his decision to become a doctor as a decision of the heart. As his career developed into leadership roles in the UK and at WHO, his head often ruled his heart but now he thinks it’s the heart that should drive us and our ambition to reduce harm.
He also highlighted six current power blocks are not doing enough to improve safety and that need to be engaged and motivated to achieve change:
- Designing of health systems - to date there is not much evidence that systems are being designed for safety.
- Health leaders - they are currently not using their power to lead for reduced harm.
- Educational institutions - we need quicker developments to train staff.
- Research community - there are questions as to whether patient safety research has led to sustainable reduction in risk.
- Data and information - he questioned how effectively this has been employed to improve patient safety.
- Industry - he noted the need for more action on this front, citing the example of the pharmaceutical industry on medication packaging and labeling and the need for more action by the medical devices industry.
Implementing the Global Patient Safety Action Plan
Dr Neelam Dhingra-Kumar (Coordinator for Patient Safety and Risk Management at the WHO) gave a presentation on the initial plans to implement a Global Patient Safety Action Plan. In this she set out the intention to set guiding principles and strategic objectives at a global level which could then be developed into actions at a country level, with the results subsequently informing SMART (Specific, Measurable, Achievable, Realistic, Time-Orientated) global patient safety goals. You can view her full presentation on the hub.
A shared vision for patient safety
The morning of the first day had contribution from global leaders on their vision for patient safety, from a patient and family perspective, from a patient safety experts, from a Ministry of Health representative and a list of proposed statements for vision, goals and guiding principles. At the very start of this session was…
Patient engagement for patient safety
Sir Liam Donaldson noted the important role that patients play in highlighting instances of unsafe care and noted that often ‘patients are not empowered to prevent their own harm’.
Sue Sheridan (Co-founder of Parents of Infants and Children with Kernicterus (PICK) and the former lead of the WHO Patients for Patient Safety programme) developed on this theme, emphasising the importance of viewing patient safety through the lens of patients and families. She noted that they had a key role to play in making change happen and co-producing safer healthcare systems. Sue identified some common threads required for co-production of safer healthcare:
- Developing a core of diverse skilled family members who are willing to be partners in this work.
- Growing and incentivising creative and passionate healthcare leaders in patient engagement in quality improvement, research and policy.
- The importance of embedding patients in governance, strategic priorities and with funded programmes.
- The need for capacity building skills for patients (to inform and influence) and for professionals (to effectively partner with patients).
- Hard-wiring budgets so that there are the funds to enable this work.
- Systematically review outcomes.
- Develop a repository of co-production best practice.
Sue highlighted that for patients and civil society to have a powerful voice, they must be supported with the appropriate tools and training and that institutions must embrace social movement with courageous leaders to co-produce safe care with patients.
Key themes of patient safety implementation
The remainder of the day was devoted to presentations on the key themes of implementation. I have listed these below and have selected a few of the topical areas to talk about in more detail that in my view, represented a new or strengthened perspective.
Theme 1: Safety in patient care, clinical processes and use of medical products and devices.
Theme 2: Patient safety policy and priorities. For the first time, patient safety has been included on the G20 agenda.
Dr Abdulelah Alhawsawi (Director General at the Saudi Patient Safety Center) outlined the important role that the G20 can play in provide leadership on a global level for patient safety. In doing this he outlined the core features of the G20 Global Patient Safety Framework that is currently being developed:
- Patient Safety Culture.
- Resilience - recognising that all clinicians have harmed, and that healthcare is complex and the need for Human factors to be employed to address systems problems.
- Advocacy - everyone knows about global climate change, but people have not heard about the global patient safety challenge. This must change and we must advocate for this change.
- Information asymmetry – the importance of effective patient and family empowerment and real co-production with patients, making sure that they have the right tools to do this.
- Collective wisdom and learning – the importance of using data and effective means of measurement.
Theme 3: Leadership and patient safety culture.
Theme 4: Patient safety education and training.
Theme 5: Human factors capability and capacity
Dr Huda Amer Al-Katheeri (Director of Strategic Planning and Performance Development in Qatar) and Dr Kathleen Mosier (President of the International Ergonomics Association) gave a presentation on the role of Human factors/ergonomics in healthcare.
In this they illustrated how poor Human factors is a healthcare in a consistent feature among patient safety failures, with systems often poorly designed and not tailored to the context/people involved. They outlined how Human factors can be integrated make healthcare systems more resilient for patient safety and the need to building these skills among workforce and enable greater participation. You can view their full presentation on the hub.
Theme 6: Measurement, reporting, learning and surveillance.
Theme 7: Patient safety research and innovation.
Theme 8: Global Patient Safety Challenges.
Theme 9: Patient engagement and empowerment.
Theme 10: Patient safety in an era of universal health coverage.
Theme 11: Developing networks and partnerships.
Theme 12: WASH – Water, sanitation and hygiene, infection prevention and control.
Coming up in part 2…
In part 2 of the blog next week, I’ll talk about the discussions that took place on the second and third days of the event, highlighting the key issues that came up in the plenary session and reflecting on how this work should be taken forward.