WORLD HEALTH ORGANIZATION FIFTY-NINTH WORLD HEALTH ASSEMBLY Provisional agenda item 11.16 A59/22 4 May 2006
Patient safety Report by the Secretariat 1. Resolution WHA55.18 urged 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 patients’ safety and the quality of health care. In this connection, the Fifty-seventh World Health Assembly welcomed the proposed creation of an international alliance to facilitate the framing of patient-safety policy and promotion of good practice in all Member States and to act as a major force for improvement internationally. 2. The World Alliance for Patient Safety was launched by the Director-General in October 2004. The World Alliance, which aims to coordinate, disseminate and accelerate improvements in patient safety worldwide, provides a vehicle for international collaboration and action between Member States, WHO’s Secretariat, technical experts, and consumers, professionals and industry groups. Its establishment underlines the importance of patient safety as a global issue. A growing body of research evidence points to the occurrence of adverse events in all health-care systems. The best available data indicates that at any given time, 1.4 million people worldwide are estimated to be suffering from an infection acquired in a health facility. Although the context may differ, no country – rich or poor – can claim fully to have come to grips with the problem of patient safety. 3. Improving patient safety requires well-designed systems of care to minimize risks to patients. Change is needed at the level of individual health-care workers, teams, organizations and whole health-care systems. Of vital importance are competent, conscientious and safety-conscious healthcare workers in frontline services who are well supported to deliver safe care.
ACTIONS AND ACHIEVEMENTS 4. A central part of global action is to formulate regional strategies for patient safety in each WHO region. Each regional office has established a patient-safety focal point who leads this work in collaboration with the World Alliance for Patient Safety. Regional strategies aim to facilitate the establishment and strengthening of patient-safety programmes within Member States by identifying country priorities, areas for regional collaboration and knowledge-sharing, and ways in which regional action can link to global work through the Alliance. Patient-safety strategies are planned or in preparation in each region.
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5. In order to support the framing of national patient-safety policies and promotion of good practices, the World Alliance has identified six main action areas, described below.1 6. The Global Patient Safety Challenge aims to identify a specific patient safety topic for a twoyear programme of action which addresses a significant area of risk relevant to all countries. Health care-associated infection was chosen as the first Global Challenge, focusing throughout 2005 and 2006 on the “Clean care is safer care” theme. The vision is to catalyse worldwide commitment to making Clean care an everyday reality everywhere health care is provided. WHO’s Secretariat is contributing to the outcome of the Global Challenge in such areas as injection practices and immunization, blood safety, safer clinical procedures, and water and sanitation. In particular, the Challenge is involved in drafting and testing WHO’s new guidelines on hand hygiene in health care, in which 200 experts from 20 countries participated; launching global and national “Clean care is safer care” campaigns and inviting Member States to pledge to take action on health care-associated infection, with the aim of initiating improvements for over half the world’s population by the end of 2006. 7. In the area of patient and consumer involvement, Patients for Patient Safety is building a patient-led, global network of patients and patient organizations to champion patient safety at country and regional levels. Consumers of health care have an important role to play both in managing risks to their own care and in building safer systems of care delivery through partnerships with health-care providers. 8. The first Patients for Patient Safety workshop (London, November 2005) brought together a group of patients and patient-safety advocates from 20 countries, who endorsed a declaration calling for a greater role for patients to improve patient safety internationally. They drew up action strategies with a strong emphasis on working in partnership with health care authorities and providers. Follow-up workshops are planned in all WHO regions during 2006 and 2007. 9. A wide range of definitions and terms are used to describe patient-safety problems. These variations hamper efforts to learn from data within and across countries. In order to draw up a patient safety taxonomy, a technical drafting group has drawn up a framework for classifying data on patientsafety problems so as to improve analysis and facilitate learning. A consultation process will take place in the second half of 2006 during which Member States will be invited to comment on the draft taxonomy so as to ensure that it is internationally acceptable. 10. In order to promote Research in the field of patient safety, an internationally agreed agenda is being drawn up with researchers, research funders, research users and consumers with input from an international consultation on research priorities (Washington DC, November 2005). Research is also being commissioned in areas in which there are significant gaps in knowledge. One of the limitations of current patient safety data is that they are primarily drawn from developed countries. The Alliance is therefore undertaking a major research project to understand the nature of patient harm in 10 developing countries and those with economies in transition and to develop measurement tools for use by Member States. 11. The search for Solutions to reduce the risk of health care and improve its safety includes promotion of existing solutions and coordination of international efforts to develop future ones. The most important component of patient-safety knowledge is how to prevent harm to patients. Safety solutions are interventions and actions that prevent patient-safety problems recurring and reduce risk 1
See World Alliance for Patient Safety. Forward Progamme 2005. Geneva, World Health Organization, 2005.
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to patients. A wide range of solutions already exists in a number of countries. The Joint Commission on Accreditation of Healthcare Organizations and Joint Commission International (United States of America) have been jointly designated as a WHO Collaborating Centre on Patient Safety Solutions dedicated to promoting and developing safety solutions. 12. Central to well targeted safety initiatives is a better understanding of the nature of the safety problems and their contributing factors. The aim of reporting and learning to improve patient safety is to provide support to Member States to establish and improve patient-safety reporting and learning systems. WHO recently drafted guidelines on adverse event reporting and learning systems, which will be the subject of consultation during 2006.
THE WAY FORWARD 13. In addition to continuing existing action, new areas of work planned for 2006 and 2007 include: • technology and education for patient safety, involving areas such as simulation methods, robotics and automation to reduce risks to patients • patient safety and the care of acutely ill patients, including support for an emerging international collaborative network • a second Global Patient Safety Challenge, focusing on a new patient safety problem of international significance • exemplar hospitals, promoting learning from best practice in patient safety in health-care facilities throughout the world. 14. WHO’s Secretariat and the Alliance will continue to work closely together in order to ensure that the needs of Member States in the context of patient safety are being effectively addressed. New networking opportunities are emerging as Member States establish national and regional patient safety centres. Core funding of US$ 44 million over five years has been provided by the United Kingdom of Great Britain and Northern Ireland, assuring a solid base on which to develop activities towards making health care safer globally. Further resources will be sought from other interested Member States, industry and other partners in order to strengthen work further.
ACTION BY THE HEALTH ASSEMBLY 15. The Health Assembly is invited to note the above report.
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