In this blog Patient Safety Learning marks World Patient Safety Day 2021. It sets out the scale of avoidable harm in healthcare, what needs to change to create a patient safe future and considers the theme of this year’s World Patient Safety Day, ‘Safe maternal and newborn care’.
Today marks the third annual World Patient Safety Day. Established by the World Health Organization (WHO) in 2019, this is intended as a day to help enhance understanding of patient safety and to engage the public in this, promoting actions to improve safety and reduce avoidable harm.[1]
Patient safety and the impact of unsafe care
The NHS describes patient safety as ‘the avoidance of unintended or unexpected harm to people during the provision of healthcare’.[2] The WHO in their definition expand on this, adding that it also involves ‘continuous improvement based on learning from errors and adverse events’.[3]
So, how big of a problem is avoidable harm in healthcare?
The WHO estimates that unsafe care is one of the 10 leading causes of death and disability worldwide.[4] It is a huge problem, with devastating consequences for patients around the world:
- Unsafe care results in over 3 million deaths each year worldwide.[5]
- It is forecast to cost the global economy approximately $383.7 billion by 2022.[6]
This also comes with an untold physical and emotional impact on those affected, in addition to a loss of trust in the healthcare systems by patients, and a loss of morale and frustration among healthcare professionals at not being able to provide the best possible care. It has been described by the G20 Health and Development Partnership as ‘the overlooked pandemic’.[7]
How do we improve patient safety?
A growing recognition of the need to make significant improvements to patient safety emerged in the 1980s and 1990s. Subsequently, in the last twenty years, there have been many international and national initiatives to better understand the causes of unsafe care and the action needed to reduce harm.
But despite the good work of many people over this time, avoidable harm in healthcare remains a persistent, wide-scale problem. At Patient Safety Learning we recognise that the main causes of unsafe care are systemic. Avoidable harm has complex roots and to make real progress we need to address these underlying systems issues.
We believe that there needs to be a transformation in our approach to tackling this problem. Key to this is patient safety being treated as core to the purpose of health and social care, not as one of several competing priorities to be traded off against each other. In our report, A Blueprint For Action, we set out an evidence-based analysis of why harm is so persistent and what is needed to deliver a patient safe future, identifying six foundations of safe care:[8]
- Shared Learning - organisations should set and deliver goals for learning, report on progress and share their insights widely for action.
- Leadership - we emphasise the importance of overarching leadership and governance for patient safety.
- Professionalising patient safety - recognising that organisational standards and accreditation for patient safety need to be developed and implemented. These need to be used by regulators to inform their assessment of safe care.
- Patient Engagement - to ensure patients are valued and engaged in patient safety.
- Data and Insight - better measurement and reporting of patient safety performance, both quantitative as well as qualitative.
- Just Culture - all organisations should publish goals and deliver programmes to eliminate blame and fear, introduce or deepen a Just Culture, and measure and report progress.
This year’s theme: Safe maternal and newborn care
Maternal and newborn care, the focus of this year’s World Patient Safety Day, is an area of healthcare that is particularly susceptible to risk.
Approximately 810 women die every day from preventable causes related to pregnancy and childbirth.[9] In addition, around 6700 newborns die every day, amounting to 47% of all under-5 deaths.[10] Moreover, about 2 million babies are stillborn every year, with over 40% occurring during labour.[11]
There is a significant gap between countries in this regard, with 94% of all global maternal deaths occurring in low- and middle-income countries.[12] Although outcomes are better in high-income countries, patient safety concerns are consistently high within maternity services, demonstrated by the many major inquiries and reviews in the UK in recent years.[13] [14] [15] [16] [17] Some key issues raised in these recent reports include:
- Lack of informed consent, with patients not being provided with all the information about what treatment involves, including benefits and risk.
- Persistence of a blame culture, discouraging staff from speaking up about unsafe care.
- Failure to listen and act on concerns raised by patients and family members.
- Barriers to and problems with multidisciplinary working in maternity care.
- Lack of support for patients after unsafe care.
- Unsafe staffing levels.
Four key objectives
The WHO has set out four key objectives for this year’s World Patient Safety Day:
- Raise global awareness on the issues of maternal and newborn safety, particularly during childbirth.
- Engage multiple stakeholders and adopt effective and innovative strategies to improve maternal and newborn safety.
- Call for urgent and sustainable actions by all stakeholders to scale up efforts, reach the unreached, and ensure safe maternal and newborn care, particularly during childbirth.
- Advocate the adoption of best practices at the point of care to prevent avoidable risks and harm to all women and newborns during childbirth.
Highlighting safety issues and sharing good practice
To mark this year’s World Patient Safety Day, we are highlighting some key areas of concern and good practice in relation to maternal and newborn safety, sharing insights, resources, and experiences on our award-winning patient safety platform, the hub, including:
- Top picks: 7 key resources for maternity safety
- Blog: Maternal care and safety in low- and middle-income countries
- Event: WHO - World Patient Safety Day 2021 Virtual Global Conference
- Resources: The maternity section of the hub
Do you have an experience to share around maternity safety, as a pregnant woman or birthing person? Or perhaps you are a healthcare professional looking to share your frontline insights to help improve safety?
Join the conversation in our community forum on the hub, or get in touch with us by emailing [email protected].
References
[1] WHO, World Patient Safety Day 2021, Last Accessed 12 September 2021. https://www.who.int/news-room/events/detail/2021/09/17/default-calendar/world-patient-safety-day-2021
[2] NHS England and NHS Improvement, Patient Safety, Last Accessed 12 September 2021. https://www.england.nhs.uk/patient-safety/
[3] WHO, Patient Safety, Last Accessed 12 September 2021. https://www.who.int/news-room/fact-sheets/detail/patient-safety
[4] WHO, Patient Safety Fact File, September 2019. https://www.who.int/features/factfiles/patient_safety/patient-safety-fact-file.pdf?ua=1
[5] The G20 Health and Development Partnership and RLDatix, The Overlooked Pandemic: How to transform patient safety and save healthcare systems, 25 March 2021. https://www.ssdhub.org/the-overlooked-pandemic/
[6] Ibid.
[7] Ibid.
[8] Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. https://s3-eu-west-1.amazonaws.com/ddme-psl/content/A-Blueprint-for-Action-240619.pdf?mtime=20190701143409.
[9] WHO, World Patient Safety Day 2021, Last Accessed 12 September 2021. https://www.who.int/news-room/events/detail/2021/09/17/default-calendar/world-patient-safety-day-2021
[10] Ibid.
[11] Ibid.
[12] WHO, Maternal Mortality, 19 September 2019. https://www.who.int/en/news-room/fact-sheets/detail/maternal-mortality
[13] Dr Bill Kirkup, The Report of the Morecambe Bay Investigation, 2015. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf
[14] The Royal College of Midwives and Royal College of Obstetricians and Gynaecologists, Review of Maternity Services at Cwm Taf Health Board, 30 April 2019. https://gov.wales/review-maternity-services-former-cwm-taf-university-health-board-report
[15] The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf
[16] Dr Bill Kirkup CBE, The Life and Death of Elizabeth Dixon: A Catalyst for Change, November 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/938638/The_life_and_death_of_Elizabeth_Dixon_a_catalyst_for_change_accessible.pdf
[17] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf
