By John Tingle
The World Health Organisation (WHO) has just produced a very informative and helpful report on the need to view patient safety as a global concern and to highlight resources that they have made available to deal with the problem and those in development. Patient safety is a fundamental principle of health care and this is fully acknowledged in the report. The report begins by quoting several facts and figures which emphasize the fact that medical errors should be regarded as a matter of acute global concern:
“According to a new study, medical errors are the third leading cause of death in the United States. In the United Kingdom, recent estimations show that on average, one incident of patient harm is reported every 35 seconds. Similarly, in low- and middle income countries, a combination of numerous unfavourable factors such as understaffing, inadequate structures and overcrowding, lack of health care commodities and shortage of basic equipment, and poor hygiene and sanitation, contribute to unsafe patient care (p1).”
Approximately two-thirds of all adverse health events happen in low-and middle-income countries. Fifteen per cent of hospital expenditure in Europe can be attributed to treating patient safety accidents.
The report clearly identifies the global nature of the patient safety problem and the personal and economic costs of errors. It works out much cheaper for everybody to take steps to avoid the errors happening in the first place.
Medical errors can occur for many reasons; they may be the result of human error or through poor systems being in place. The most common adverse patient safety incidents are stated in the report:
- surgical procedures (27%)
- medication errors (18.3%)
- health care -associated infections (12.2%) (p.2)
Fear around reporting of errors is prevalent in many health care cultures and the report says is impeding progress and learning for improvement and error prevention.
How has the world been doing on patient safety?
According to the report global progress on patient safety has been very slow and limited. Efforts have been made but many have been piece meal, uncoordinated and un-sustained.
Providing global leadership and fostering collaboration.
The report provides details of WHO patient safety initiatives, tools and publications and those in development. Some of these such as the WHO Surgical Safety Checklist, WHO Safe Childbirth Checklist are well known but others such as the Global Patient Safety (GPS) Network or the Global Knowledge Sharing Platform for Patient Safety (GKPS) will be less well known. Projects in development include patient safety incident reporting and learning guidelines. The development of a comprehensive guide to engaging patients and families as part of efforts to build country capacity in developing safe health systems which embed the concepts of patient and family engagement and people –centeredness. The development of patient safety measurement tools and country measurement for responding to growing country needs to monitor patient safety improvements.
The WHO report is excellent and should be essential reading for all those concerned with patient safety and health quality improvement. It sums up well the problems in the area and advances some key solutions. There are no easy answers to bringing about the development of effective patient safety cultures globally. The WHO role as the global lead facilitator will do much to advance the global patient safety agenda.