Today, the World Health Organization (WHO) and its partners announced a series of key actions to cut the number of illnesses, injuries and deaths suffered by patients during health care, with the launch of the World Alliance for Patient Safety. WHO, ministers of health and senior officials, academics and patients’ groups have come together from all corners of the globe to advance the patient safety goal of “First do no harm”1 and reduce the adverse health and social consequences of health care.
“Improved health care is perhaps humanity’s greatest achievement of the last 100 years,” said WHO Director-General LEE Jong-wook. “Improving patient safety in clinics and hospitals is in many cases the best way there is to protect the advances we have made.”
This is the first time that a coalition of partners has joined efforts to act globally to improve patient safety. This underlines the critical need to take effective, visible and concerted action to reduce the growing number of adverse effects in health care and their impact on patients lives.
A number of countries have already initiated patient safety plans and legislation. Political leaders from several countries are playing a key role in supporting the development of research, delivery capabilities and knowledge to tackle the full range of patient safety issues on a worldwide scale. In particular, two partners of the Alliance – the Department of Health of the United Kingdom and the Department of Health and Human Services of the United States of America – are committing resources and expertise to start reversing the escalating incidence of preventable adverse effects in health-care.
“Patient safety is a global problem. The interest and commitment being shown by countries around the world to finding solutions is inspiring. Over the years ahead, throughout the world, lives will be saved, risks to patients will be reduced and many lessons will be learned as a result of the action being launched in Washington, DC today,” said Sir Liam Donaldson, Chief Medical Officer of the United Kingdom Government, who chairs the World Alliance for Patient Safety.
The creation of the World Alliance comes two years after the Fifty-fifth World Health Assembly Resolution on Patient Safety in 2002 called on Member States to pay the closest possible attention to the problem of patient safety and to establish and strengthen science-based systems necessary for improving patient safety and quality of health care, including the monitoring of drugs, medical equipment and technology. The resolution urged WHO to take the lead in developing global norms and standards, encouraging research, and supporting efforts by Member States in developing patient safety policy and practice.
“This global initiative will ensure that all nations work together to improve health care and patient safety – issues that are not bound by geographical borders,” said Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services. “We have seen much progress in the last five years, but we have a long way to go to ensure that health care services provided around the world are as safe as they can be.”
Adverse events in health care delivery cause many cases of illness, injury and death. Studies in a number of countries have shown a rate of adverse events between 3.5% to 16.6%2 among hospital patients. An average of one in every ten patients admitted to hospital suffers some form of preventable harm that can result in severe disability and even death.
Added to the considerable human misery is the economic impact of adverse effects. Several studies have shown that additional hospitalisation, litigation claims, hospital-acquired infections, lost income, disability and medical expenses cost some countries between US$ 6 billion and US$ 29 billion a year.3
“Adverse events in health care delivery is a problem that affects every country, every hospital, every health clinic around the world, from doctors and specialists to nurses and health workers,” said Dr Mirta Roses, Regional Director of the WHO Office for the Americas.
“The situation is far more serious in developing countries, with millions of child and adult patients enduring prolonged ill-health, needless disability and even death caused by medical errors, unsafe blood transfusions, counterfeit and substandard drugs, and overall unreliable practices within poor work conditions,” said Dr Ebrahim Samba, Regional Director of the WHO Office for Africa. WHO reports that at least 50% of all medical equipment is unsafe, and that 77% of all reported cases of counterfeit and substandard drugs occur in developing countries.
The Alliance has a firm objective to deliver six programmes within the next two years:
- A key element will be the Global Patient Safety Challenge, focusing over 2005-2006 on the challenge of health-care associated infection;
- Patients for Patient Safety involving patient organizations and individuals in Alliance work;
- Taxonomy for Patient Safety ensuring consistency in the concepts, principles, norms and terminology used in patient safety work;
- Research for Patient Safety developing a rapid assessment tool for use in developing countries and undertaking global prevalence studies of adverse effects;
- Solutions for Patient Safety promoting existing interventions and coordinating activity internationally to ensure new solutions are delivered;
- Reporting and Learning generating best practice guidelines for existing and new reporting systems, and facilitating early learning from information available.
The World Alliance for Patient Safety will build on existing national efforts and initiatives sharing the same vision and link with programmes for improving patient safety. It is expected that its work will eventually lead to much greater long-term safety in health care. The impact of well-developed and well-applied strategies on patient safety is expected to include a dramatic decrease in adverse effects in health care and a decline in expenditure in the order of billions of dollars of saved costs annually.
1“First do no harm”, attributed to Hippocrates circa 460-370 BC
2 Wilson RM, Runchiman WB, Gibberd RW et al The Quality in Australian Health Care Study. Med J Aus 1995, 163: 458-71; Davis P, Lay -Yee, Briant R et al. Adverse events in New Zealand public hospitals I: occurrence and impact. NJ Med J 2002;115 (1167):U271 ; Davis P, Lay -Yee, Briant R et al. Adverse events in New Zealand public hospitals II: occurrence and impact. NJ Med J 2003;116 (1183):U624; Baker GR, Norton PG, Flintolf V, et al. The Canadian Adverse events Study: the incidence of adverse events among hospital patients in Canada. JAMC 25 may 2004 179 (11) 1678 – 1686; Vriens M, Blok H, Fluit A, et al. Costs associated with a strict policy of eradicate MRSA in a Dutch University Medical Centre. A 10 Year Survey. European Journal of Clinical Microbiology and Infectious Diseases. 2002, 21:782-786;
3Department of Health. An organisation with a memory. Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. HMSO 2000. Crown Copyright; Kohn, LT, Corrigan, JM, Donaldson, MS Eds. (1999) To err is human: Building a safer health system. Institute of Medicine, National Academy Press.