WHO PATIENT SAFETY PROGRAMME Carmen Audera WHO Patient SAFETY Meeting the Challenges Faced by Emerging Countries in the Provision of Quality Primary Health Care Cape Town
A 23 year old women in her first pregnancy delivered a baby boy by normal vaginal delivery in the hospital, but patient developed postpartum haemorrhage. She was not under immediate close observation following the delivery. Several hours later she was taken to operating theatre and was given blood and fluid resuscitation. On examination the uterus was very lax. Synticinone and ergometrine were administered, but still uterus was lax. Finally a laparotomy was performed and a hysterectomy was done. The patient died on the operating table. This should not have happened!!!
WHAT IS PATIENT SAFETY Patient safety is the absence of avoidable harm to patients during the process of health care. The International Classification for Patient Safety describes patient safety as the reduction of risk of unnecessary harm associated with health care to an acceptable minimum. An acceptable minimum refers to the collective notions of given current knowledge, resources available and the context in which care was delivered, weighed against the risk of non-treatment or other treatment.
WHAT IS PATIENT SAFETY Patient safety: A critical dimension of quality : Should be considered within the context of health care delivery and health systems. An issue for all countries: Nature of problems is certainly different-
WHY IS PATIENT SAFETY A PROBLEM
Why is patient safety a global public health problem Every year, tens of millions of patients worldwide suffer disabling injuries or death due to unsafe medical care.
Some data Estimates show that in developed countries as many as one in 10 patients is harmed while receiving hospital care. The harm can be caused by a range of errors or adverse events. An adverse event is an incident which resulted in harm to a patient (including omission)
Adverse events in health care : Developed and developing countries Developed countries HCAI: 5 million HCAI estimated to occur in hospitals in Europe/year 1.7 million HCAI in USA - about 100,000 deaths Developing countries HCAI: Neonatal HCAI 3-20 times higher in developing world Risk of SSI is higher than developed world: 40% in paediatrics (Nigeria); 23% general surgery (Tanzania); 19% in maternity (Kenya)
Adverse events in health care : Developed and developing countries Developed countries Developing countries Unsafe surgery: 0.4-0.8% permanent disability or death rate Unsafe surgery: 5-10% permanent disability or death rate Blood safety Countries implementing strategies for blood safety prevent the transmission of infections Blood safety: Africa has highest rates of transmissible diseases through unsafe blood transfusion (8% hepatitis B, 2.5-10% hepatitis C)
Adverse events in health care : Developed and developing countries Developed countries Injection Safety: Injections used as necessary Single use of injection devices Developing countries Injection safety: In developing and transitional countries, 16 billion injections administered /year In parts of developing world 70% of injections are unnecessary ( or could be given orally) Reuse of injection devices account for about 260 000 new HIV infections /year and 2,3 to 4,7 millions new cases of hepatitis B/C
Adverse events in health care : Developed and developing countries Developed countries Counterfeit drugs: In countries with effective regulatory systems incidence of counterfeit drugs is less than 1% Developing countries Counterfeit drugs: In many African countries, and in parts of Asia, Latin America, a much higher percentage of the medicines on sale may be counterfeit ( can be as high as 77% of all reported cases).
The magnitude of the problem How Does Safety Burden Compare to Other Medical Causes of Disability? Cause Disability-adjusted life years lost Adverse Events 37.3M Cerebrovascular Disease Ischemic Heart Disease 46.6M 62.6M Malignant Neoplasm 77.8M Schizophrenia 16.3M Depression 65.5M
.Why does this happen Hippocratic oath: '. do no harm' is rarely voluntarily violated by health professionals, however every day patients are harmed during health care or suffer from not receiving the right treatment, (omission) in every country of the world
PATIENT SAFETY Human beings make mistakes because the systems, tasks and processes they work in are poorly designed. Dr Lucian Leape, testifying to the US President s Commission on Consumer Protection and Quality in Health
THE SWISS CHEESE MODEL SUCCESSIVE LAYERS OF DEFENCES Physical barriers Procedures Information Decisions Adapted from Professor James Reason
The Swiss Cheese Model: DEFENCES Essential equipment Clinical policy Risk management plan Skilled staff THE GAPS Inadequate staff knowledge Monitoring unavailable Interventions ill defined Poor handling of emergency
Issues: The 10 domains in developing countries in order of relevance 1. Health care associated infections (HAI) 2. Preventable adverse drug events 3. Adverse events in mother and/or baby related to prenatal, labor and postnatal care period. 4. Adverse events due to surgical and anesthetic care 5. Adverse events related to wrong and/or late diagnosis 6. Adverse events related to injection practices 7. Adverse events related to unsafe use of blood and blood products 8. Adverse events related to medical device use 9. Patients falls and injuries due to falls 10. Pressure ulcers
RISKS TO PATIENT SAFETY Poor test follow-up Misdiagnosis Workload pressures Stress and fatigue of health care staff Poor safety culture Poor training of health care staff Poor patient identification Inadequate use of protocols Organizational/ system failures Poor health system accountability
Economic Impact of Unsafe Care Medical errors USA: annual impact, $19.5 billion (2008) Health care-associated infections (HCAI) Europe: 13-24 billion/ year Euros (or an average of 25 million extra days hospital stay) USA: annual impact, $ 6.5 billion (2004) (WHO HH Guidelines, 2009) Medication errors: USA: annual impact, $ 3.5 billion(2006)
PATIENT SAFETY PROBLEM " Unsafe care is not only about numbers and statistics but involves damage to the lives of real people patients and their families- who are harmed and sometimes die as a result of unsafe care. It also affects the lives of doctors, nurses and other health care staff who become the 'second victims' in a chain of events. Sir Liam Donaldson Former Chief Medical Officer UK
PATIENT ARE HARMED
WHO AND PATIENT SAFETY 2002: 55th World Health Assembly Resolution. MS requested WHO to build global standards and support MS 2003: Many countries started to implement patient safety initiatives and request WHO technical support 2004: Launch of the World Alliance for Patient Safety 2009: Patient Safety Programme The Patient Safety Programme: Housed at WHO/Patient Safety Programme Chair is Sir Liam Donaldson Offices in Geneva and London- 25 staff
WHO patient safety The mission of WHO Patient Safety is to coordinate, facilitate and accelerate patient safety improvements around the world. It provides a vehicle for international collaboration and action between WHO Member States, WHO s Secretariat, technical experts, and consumers, as well as professionals and industry groups.
FROM PROBLEM TO SOLUTION 5 ELEMENTS FOR SAFER HEALTH CARE Research to understand patient safety challenges Knowledge access, use and evaluation Collaborations & partnerships DRIVING FORCES Strengthening capacity; educating for safety SAFER HEALTH CARE Political commitment and leadership Dynamic (global and national) movements to engage and sustain commitment Developing guidelines, standards, solutions and protocols for PS
10 STRATEGIES FOR SAFER CARE 1 2 3 4 5 Clean Care is Safer Care. Strategies and tools to reduce health care-associated infection, through hand hygiene; government engagement, to support global and national hand hygiene campaigns. Safe Surgery Saves Lives Checklist embedded in an implementation strategy to save lives by ensuring safe surgical practices are followed. Safe Childbirth Checklist for ensuring safe practices during pregnancy and childbirth. The African Partnerships for Patient Safety for building links between Africa and Europe to help tackle patient safety in Africa. The International Classification for Patient Safety Framework for defining patient safety information linked to applying the Reporting and Learning systems to identify causes of risk and promote learning.
STRATEGIES FOR SAFER CARE 10Research for better knowledge to make care safer, 6 through establishing priorities, knowledge management, developing tools to assess harm and supporting research in developing countries. 7 Solutions for Patient Safety to translate knowledge into practical solutions. 8 Standardized patient safety protocols to achieve sustainable reductions in the occurrence of serious patient safety problems. 9 Patient Safety Curricula Guides to educate and train future health care workers as leaders in patient safety. 1 0 Patient for Patient Safety creating honourable partnerships between patients and the health care community and giving patients a voice.
1: CLEAN CARE IS SAFER CARE Vision: Making infection prevention & control, with hand hygiene as the essential basis, a priority in health care everywhere Guidelines: Finalised and issued 2009 Tools: New tools available: http://www.who.int/gpsc/5may/ tools/en/index.html May 5: Action for sustained Hand Hygiene: Sign Up! http://www.who.int/gpsc/5may/ register/en/index.html
Prevalence of nosocomial infections in the world Developed countries Range: 5.1-11.6% The Burden of Health Care-Associated Infection Worldwide: A Summary - First Global Patient Safety Challenge http://www.who.int/gpsc/
Prevalence of nosocomial infections in the world Developing and countries with economies in transition Range: 5.7-19.1% The Burden of Health Care-Associated Infection Worldwide: A Summary - First Global Patient Safety Challenge http://www.who.int/gpsc/
1: CLEAN CARE IS SAFER CARE 122 Member States pledged to tackle HCAI 42 Member States participate WHO CleanHandsNet Jan 2011 October 2009 Over 12,000 health care facilities from 122 countries registered for SAVE LIVES: Clean Your Hands May 5 : Sign Up! http://www.who.int/gpsc/5may/register/en/index.html
2: SAFE SURGERY SAVES LIVES It is estimated that every year in the world 234 millions mayor surgery interventions take place 1 in every 25 people It is estimated that 25% of hospital surgery presents some kind of complication 7 million complications per year It is estimated that between 0.5 5% of all surgical interventions lead to death Approximately 1 million deaths per year
2. THE SAFE SURGERY SAVES LIVES STRTATEGY 1. Creation of a checklist to improve the standards of surgical safety
The list was piloted in 8 sites PAHO I Toronto, Canada EURO London, UK EMRO Amman, Jordan PAHO II Seattle, EU WPRO I Manila, Philipines AFRO If Kara, Tanzania SEARO New Delhi, India WPRO II Auckland, NZ
2. CHECKLIST REDUCES DEATH BY1/3 Baseline Checklist P value Checklist was tested in 8 pilot sites worldwide and was found to reduce the rate of postoperative complications and death by more than one-third Cases 3733 3955 - Death 1.5% 0.8% 0.003 Any Complication 11.0% 7.0% <0.001 SSI 6.2% 3.4% <0.001 Unplanned Reoperation 2.4% 1.8% 0.047
http://www.who.int/patientsafety/safesurgery/ho spital_form/en/index.html
Global pulse oximetry project Promoting PO technology as standard of care using WHO Checklist as entry point Development of low cost Pulse Oximeter Pilot testing Use of a surgical checklist Reduction of hypoxia time Reduce morbidity and mortality Building a procurement system
Safe Childbirth Checklist A simple tool that aims to assist childbirth teams in assuring that all essential clinical practices are performed. Single Centre testing in Belgaum, India Preliminary findings suggest a significant improvement in a selection of key indicators: Washing hands and wearing gloves when doing exam Administering oxytocin 1 minute after birth Using partograph for each labouring woman Study ongoing Larger study planned in all Regions
Mother and Baby Safer Care Tool Patient developed tool to help mothers recognize and act on danger signs post childbirth Paper version in development Mobile phone and voice recognition under development
4: AFRICAN PARTNERSHIPS FOR PATIENT SAFETY Strengthens care delivery: situations analysis, identifying resources available, direct transfer of know-how from North to South and South to North
5: INTERNATIONAL CLASSIFICATION FOR PATIENT SAFETY A standardized classification for patient safety concepts and language to share learning worldwide Defining, harmonizing and grouping patient safety concepts into an internally agreed classification The conceptual framework: has been developed and is being used by at least 15 countries and disseminated worldwide
6. PATIENT SAFETY RESEARCH "Better knowledge for safer care" Objective: to facilitate the spread and use of research findings to inform safer health care worldwide through: Unveiling the problem of unsafe care and raising awareness providing guidance regarding patient safety research strengthening capacity for research evaluating effectiveness of PS measures
6. PATIENT SAFETY RESEARCH: Country studies
For the Study conducted in South Africa Out of all cases, 8.2% of admissions were associated with an Adverse Event during hospitalization. 24% of these cases suffered permanent disability or death as a consequence of the adverse events. Admissions with Adverse Events incurred an additional 6.5 bed days. More than 50% of the Adverse events were determined to be highly preventable.
Tools to measure harm Retrospective record review Record review of current in-patients Staff interview on current inpatients Nominal group technique Direct observation and related interviews
Small grants programme Initiated in 2008 Provides seed funds for 15-20 small research projects per year Amount of the grant between 10 000 and 25 000 US$ Objective is to contribute to building local capacity for research on patient safety specially in developing countries
Small grants in Sub-Saharan Africa Patient safety culture in health facilities in Ghana Impact of disposable glove use on the health-care workers' compliance with hand hygiene during care. Mali Impact of hand hygiene and disinfection of stethoscopes on the potential of health care-associated infection transmission by stethoscopes in Nigeria Situational analysis of injection practices in health care. Uganda Molecular residual risk of transfusion transmitted viral infections in pretransfused blood in Tanzania Effectiveness of health education intervention on the documentation and reporting of adverse medication events in a Nigerian teaching hospital A comparison of medical records review and incident reporting for in-patient adverse event assessment. Kenya
7: PATIENT SAFETY SOLUTIONS- AIDE MEMOIRS Solutions aim at redesigning care processes to prevent harm to patient. Useful tool to raise awareness and commitment by decision makers to patient safety WHO designated the Joint Commission Intl. as the Collaborating Centre on Patient Safety to develop the Solution Aide Memoires. 9 solutions Aide Memoirs developed and released in 2007: - Look-Alike, Sound-Alike Medication Names - Patient Identification - Communications During Patient Handovers - Performance of Correct procedure at Correct Body Site - Control of Concentrated Electrolyte Solutions - Assuring Medication Accuracy - Single Use of Injection Devices - Avoiding Catheter and Tubing Mis-Connections - Improved hand hygiene One solution developed in 2008 - Preventing Central Line-Associated Bloodstream Infections
8: STANDARD OPERATING PROTOCOLS The project seeks to bring local variations in health care practice into a global ideal of patient safety by developing standardized protocols that can be applied in any hospital, anywhere in the world. Three SOPs : Managing Concentrated Injectable Medicines (Heparin, Morphine, KCl) Medication Accuracy at Transitions in Care Performance of Correct Procedure at Correct Body Site Detailed evaluation framework and data collection tools: to evaluate protocols and see improvements in the risks they address
9: PATIENT SAFETY CURRICULM GUIDE 2009: Launch of the Patient Safety Curriculum Guide for Medical Schools 2010: Evaluation of Curriculum Guide for Medical School in 12 pilot sites (9 countries) 2010: Patient Safety Curriculum Guide: Multi-professional edition initiated 2011: Launch of Multiprofessional Patient Safety Curriculum Guide
9: PATIENT SAFETY CURRICULM GUIDE Objective: Strengthen health systems by educating future healthcare professionals in patient safety PS Multi-professional Curriculum Guide: developed to engage faculty and introduce Patient Safety topics to medical, nursing, midwifery, dentistry and pharmacy students. Part A: Teacher s Guide - Designed to build capacity for patient safety education and programme planning and design. Part B: 11 topics/modules on patient safety - Flexible, adaptable to country universities- can enter at any stage -Complete curriculum or use selective topics on case by case basis
10. PATIENTS FOR PATIENT SAFETY Recognize the essential role and value of patient involvement as a catalyst for change PFPS works with a global network of patients, consumers, caregivers, and consumer organizations to support patient involvement in patient safety programmes, in countries and globally. (100 Champions) Champions have been very successful in raising awareness
PFPS Champion Activity Patients Organizations Training Courses Media Campaigns Networking Journal Articles Patient Materials Presentations to Healthcare workers Medical Students Patients Hospital boards National groups Health Ministers Committees Health quality and hospital boards Health ministries WHO expert committees
Patient Safety situation in Africa In the African region, most countries lack national policies and plans on safe and quality health-care practices. Inappropriate funding of health care systems, unavailability of critical support systems including strategies, guidelines, tools and patient safety/quality of health care standards remain major concerns in the Region. Weak health care delivery systems including sub-optimal infrastructure, poor management capacity and under-equipped health facilities have brought about a situation where the likelihood of adverse events is high. The overuse, underuse or misuse of medicines: black market medicines, medicines in the streets, counterfeit A lack of adequate infection control within health care facilities
Unsafe surgical care: very few countries in the Region systematically use the safe surgery saves lives check-list recommended by WHO. Serious risk of infection from blood borne pathogens and other infections such as TB for health-care workers including lab personnel; Implementation of blood safety remain an important challenge in the Region Shortages of human resources, low level of staff preparedness and lack of continuing medical education Lack of partnership involving patients and civil society in improving patient safety Inadequate data on patient safety issues.
The challenges of patient safety in developing countries including African countries - Patient Safety is a new concept not always easy to understand - Patient Safety is not seen as a priority when health systems are faced with other pressing health issues - There is a blame culture which leads to occultism - Often there is a fatality mentality Things are like this here!
What is WHO PS Programme proposing Simple solutions that make a change! - Hand washing, checklists, protocols, standard procedures, local solutions. Change in Patient safety culture - Communication, Leadership, Learning from errors. Commitment Integrate patient safety into all aspects of Health care -patient safety as a crosscutting issue Integrate Patient Safety into training curricula of health professionals
Can it be done? Michigan, USA Reductions in ICU catheter-related blood stream infections across the whole State of Michigan USA The work of Professor Peter Pronovost s team at Johns Hopkins University Hospital
Thank you very much for your attention