WORLD PATIENT SAFETY DAY

SEP 17th, 2019

NAMDINH GENERAL HOSPITAL

MEETING HALL. 7.15 am
 No one should be harmed in
healthcare and yet...
• 134 million adverse events occur each year
due to unsafe care in hospitals in low- and
middle-income countries, contributing to 2.6
million deaths annually
• 15% of hospital expenses can be attributed to
treating patient safety failures in OECD
countries
• 4 out of 10 patients are harmed in the primary
and ambulatory settings; up to 80% of harm in
these settings can be avoided
Patient Safety: a global health priority
On the first-ever World Patient Safety Day on 17
September 2019, WHO will launch a global
campaign to create awareness of patient safety
and urge people to show their commitment to
making healthcare safer.
Light up a monument
The City of Geneva will light up the Jet d’Eau in
recognition of the first World Patient Safety Day! Other
cities around the world will join us in lighting up a
monuments on 17 September. Tell us about your plans
to light up a prominent monument, public space, or
natural feature with the colour orange.
 Patient Safety. Key facts

• Adverse events due to unsafe care is likely one of the

10 leading causes of death and disability in the
world.
• In high-income countries, it is estimated that 1/10
Pts is harmed while receiving HC. The harm can be
caused by a range of adverse events, with nearly 50%
of them being preventable.
• 134 million adverse events occur each year in
hospitals in LMICs, resulting in 2.6 million deaths
annually due to unsafe care.
• Another study has estimated that around 2/3 of all
adverse events resulting from unsafe care, and the
years lost to disability and death occur in LMICs.
• Globally, as many as 4 in 10 patients are harmed in
primary and outpatient HC. Up to 80% of harm is
preventable. The most detrimental errors are related
to diagnosis, prescription and the use of medicines.
• 15% of total hospital activity and expenditure in
OECD countries is a direct result of adverse events.
• Investments in reducing patient harm can lead to
significant financial savings, and more importantly
better patient outcomes (2). An example of
prevention is engaging patients, if done well, it can
reduce the burden of harm by up to 15%
 What is Pt Safety?
• Pt Safety is a HC discipline that emerged with the
evolving complexity in HC systems and the resulting
rise of Pt harm in HC facilities. It aims to prevent and
reduce risks, errors and harm that occur to Pts. A
cornerstone of the discipline is continuous
improvement based on learning from errors and
adverse events.
• To ensure successful implementation of Pt safety
strategies; clear policies, leadership capacity, skilled
HC professionals and effective involvement of
patients in their care, are all needed.
 Why does patient harm occur?

• A mature health system takes into account the

increasing complexity in HC settings that make
humans more prone to mistakes. For example, an in-
Pt might receive a wrong medication because a mix-
up that occurred due to similar packaging. In this
case, the prescription passed through different levels
of care starting with the doctor in the ward to the
pharmacy for dispensing and finally to the nurse who
administered the wrong medication to the Pt.
In this case, lack of standard procedures for
storage of medications that look alike, poor
communication between different providers, lack
of verification before medication administration
and lack of involvement of Pts in their own care
might all be underlying factors and system flaws
that led to the occurrence of errors.
• 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 (7). Humans are guarded
from making mistakes when placed in an error
proof environment where the systems, tasks and
processes they work in are well designed (8).
Therefore, focusing on the system that allowed
harm to occur is the beginning of improvement
which can only occur in an open and transparent
environment where a safety culture prevails.
 Burden of harm
• Every year, millions of Pts suffer injuries or die because of
unsafe and poor-quality HC. Many medical practices and
risks associated with HC are emerging as major challenges
for Pt safety and contribute significantly to the burden of
harm due to unsafe care. For example:
• Medication errors are a leading cause of injury and
avoidable harm in HC systems: globally, the cost associated
with medication errors has been estimated at US$ 42 billion
annually ;
• HC-associated infections occur in 7 and 10 out of every 100
hospitalized patients in high-income countries and low- and
middle-income countries respectively (11);
• Unsafe surgical care procedures cause complications in up
to 25% of patients; almost 7 million surgical patients
annually suffer significant complications, 1 million of whom
die during or immediately after surgery
• Unsafe injections practices in HC settings can transmit
infections, including HIV and hepatitis B and C, and
pose direct danger to Pts and HC workers; they account
for a burden of harm estimated at 9.2 million years of
life lost to disability and death worldwide;
• Diagnostic errors occur in about 5% of adults in
outpatient care settings, more than half of which have
the potential to cause severe harm. Most people will
suffer a diagnostic error in their lifetime;
• Unsafe transfusion practices expose patients to the
risk of adverse transfusion reactions and transmission
of infections;
• Radiation errors involve overexposure to radiation and
cases of wrong-patient and wrong-site identification;
Sepsis is frequently not diagnosed early enough to
save a Pt’s life; as these infections are often
resistant to antibiotics, they can rapidly lead to
deteriorating clinical conditions, affecting an
estimated 31 million people worldwide and
causing over 5 million deaths/year;
Venous thromboembolism – vein clots – is one of
the most common and preventable causes of Pt
harm, contributing to 1/3 of the complications
attributed to hospitalization. Annually, there are
estimated to be 3.9 million cases in high-income
countries and 6 million cases in LMICs.
 Patient Safety - a fundamental component for
Universal Health Coverage

Safety of Pts during the provision of health

services that are safe and of high quality is a
prerequisite for strengthening HC 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)