Patient Safety Awareness Week is an annual recognition event intended to encourage everyone to learn more about health care safety. During this week, IHI seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce.
Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognizing the work already being done.
Patient Safety is a healthcare discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors, and harm that occur to patients during the provision of health care. A cornerstone of the discipline is a continuous improvement based on learning from errors and adverse events.
Patient safety is fundamental to delivering quality essential health services. Indeed, there is a clear consensus that quality health services across the world should be effective, safe, and people-centered. In addition, to realize the benefits of quality health care, health services must be timely, equitable, integrated, and efficient.
To ensure successful implementation of patient safety strategies; clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals, and effective involvement of patients in their care, are all needed.
Although there has been real progress made in patient safety over the past two decades, current estimates cite medical harm as a leading cause of death worldwide.
The World Health Organization estimates that 134 million adverse events occur each year due to unsafe care in hospitals in low- and middle-income countries, resulting in some 2.6 million deaths. Additionally, some 40 percent of patients experience harm in ambulatory and primary care settings with an estimated 80 percent of these harms being preventable, according to WHO.
Some studies suggest that as many as 400,000 deaths occur in the United States each year as a result of errors or preventable harm. Not every case of harm results in death, yet they can cause a long-term impact on the patient's physical health, emotional health, financial well-being, or family relationships.
Preventing harm in health care settings is a public health concern. Everyone interacts with the health care system at some point in life. And everyone has a role to play in advancing safe health care.
A mature health system takes into account the increasing complexity in health care settings that make humans more prone to mistakes. For example, a patient in a hospital might receive the wrong medication because of a mix-up that occurs due to similar packaging. In this case, the prescription passes through different levels of care starting with the doctor in the ward, then to the pharmacy for dispensing, and finally to the nurse who administers the wrong medication to the patient. Had there been safeguarding processes in place at the different levels, this error could have been quickly identified and corrected. In this situation, a lack of standard procedures for storage of medications that look alike, poor communication between the different providers, lack of verification before medication administration, and lack of involvement of patients in their own care might all be underlying factors that led to the occurrence of errors.
Traditionally, the individual provider who actively made the mistake (active error) would take the blame for such an incident occurring and might also be punished as a result. Unfortunately, this does not consider the factors in the system previously described that led to the occurrence of an error (latent errors). It is when multiple latent errors align that an active error reaches the patient.
To err is human, and expecting flawless performance from human beings working in complex, high-stress environments is unrealistic. Assuming that individual perfection is possible will not improve safety. Humans are guarded against making mistakes when placed in an error-proof environment where the systems, tasks, and processes they work in are well designed.
Therefore, focusing on the system that allows harm to occur is the beginning of improvement, and this can only occur in an open and transparent environment where a safety culture prevails. This is a culture where a high level of importance is placed on safety beliefs, values, and attitudes and shared by most people within the workplace.
Every year, millions of patients suffer injuries or die because of unsafe and poor-quality health care. Many medical practices and risks associated with health care are emerging as major challenges for patient safety and contribute significantly to the burden of harm due to unsafe care. Below are some of the patient safety situations causing the most concern.
Safety of patients during the provision of health services that are safe and of high quality is a prerequisite for strengthening health care systems and making progress towards effective universal health coverage (UHC) under Sustainable Development Goal 3 (Ensure healthy lives and promote health and well-being for all at all ages).
Target 3.8 of the SDGs is focused on achieving UHC “including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.” In working towards the target, WHO pursues the concept of effective coverage: seeing UHC as an approach to achieving better health and ensuring that quality services are delivered to patients safely.
It is also important to recognize the impact of patient safety in reducing costs related to patient harm and improving efficiency in health care systems. The provision of safe services will also help to reassure and restore communities’ trust in their health care systems.
The Patient Safety and Risk Management unit at WHO has been instrumental in advancing and shaping the patient safety agenda globally by focusing on driving improvements in some key strategic areas through:
WHO's work on patient safety began with the launch of the World Alliance for Patient Safety in 2004 and this work has continued to evolve over time. WHO has facilitated improvements in the safety of health care within Member States through the establishment of Global Patient Safety Challenges. Each of the Challenges has identified a patient safety burden that poses a major and significant risk. The challenges thus far have been:
WHO has also provided strategic guidance and leadership to countries through the annual Global Ministerial Summits on Patient Safety, which seek to advance the patient safety agenda at the political leadership level with the support of health ministers, high-level delegates, experts, and representatives from international organizations.
WHO has been pivotal in the production of technical guidance and resources such as the Multi-Professional Patient Safety Curriculum Guide, Safe Childbirth Checklist, the Surgical Safety Checklist, Patient Safety solutions, and 5 Moments for Medication Safety (available in print and in App form).
To promote global solidarity, WHO has also encouraged the creation of networking and collaborative initiatives such as the Global Patient Safety Network and the Global Patient Safety Collaborative. Recognizing the importance of patients’ active involvement in the governance, policy, health system improvement, and their own care, the WHO also established the Patients for Patient Safety program to foster the engagement of patients and families.
Sources:
http://www.ihi.org/Engage/Initiatives/Patient-Safety-Awareness-Week/Pages/default.aspx
https://forward.centerforpatientsafety.org/patient-safety-awareness-week-psaw
https://www.who.int/campaigns/world-patient-safety-day/2019
https://www.who.int/news-room/fact-sheets/detail/patient-safety