Organizers: Saudi Arabia, Japan, Germany, the United Kingdom of Great Britain and Northern Ireland and the WHO Secretariat
Co-sponsors: China, Czechia, Denmark, Italy, Kenya, Luxembourg, Malta, Norway, Oman, Poland, South Africa, Sri Lanka and Switzerland
Chairs
- His Excellency Dr Tawfiq bin Fawzan bin Muhammad Al-Rabiah, Minister of Health, Saudi Arabia
- Dr Yasuhiro Suzuki, Vice-Minister for Health, Chief Medical and Global Health Officer, Ministry of Health, Labour and Welfare, Japan
- Mr Jens Spahn, Federal Minister of Health, Germany
- Mr Jeremy Hunt, Secretary of State for Health and Social Care, United Kingdom
- Dr Soumya Swaminathan, Deputy Director-General for Programmes, WHO Geneva
- Dr Naoko Yamamoto, Assistant Director-General, Universal Health Coverage and Health Systems, WHO Geneva
Background
Patient Safety is a critical global public health issue and has a widely accepted role in enabling health systems to achieve effective Universal Health Coverage (UHC). Patient harm is one of the leading causes of global disease burden, with unsafe medication practices and medication errors representing the leading cause of injury and avoidable harm in health care systems across the world. Acknowledging that unsafe care exerts a very high public health burden worldwide physically, psychologically, and economically, the Director-General of WHO, Dr Tedros Adhanom Ghebreysus, emphasized the essential role of patient safety in achieving UHC at the 6th Annual World Patient Safety, Science and Technology summit in February 2018.
Following the third Global Ministerial Summit on Patient Safety in April 2018 and endorsement of the Tokyo Declaration on Patient Safety at the Summit, this side event brought together country leaders, policy-makers, experts, patients’ networks, NGOs, civil society and Member States, and provided an opportunity to countries from all WHO regions to review the underlying systemic issues affecting patient safety, share experiences in addressing barriers and creating solutions to strengthen systems and improve practices. The event was not only a call to action and recognition of the need to implement the WHO Global Patient Safety Challenge: Medication Without Harm, but also an opportunity to learn and strengthen international collaboration to improve patient safety in coordination with achieving UHC.
Summary of Ministerial Statements
Building on momentum from the series of Global Ministerial Summits on Patient Safety (Tokyo Summit in 2018, Bonn Summit in 2017 and UK Summit in 2016), Member States reinforced their enthusiasm and commitment towards improving Patient Safety. His Excellency Dr Tawfiq bin Fawzan bin Muhammad Al-Rabiah, Minister of Health of Saudi Arabia opened the meeting and welcomed all the panelists and all the attendees, followed by Mr Jeremy Hunt, Secretary of State for Health and Social Care in the United Kingdom and all co-chairs reinforced their countries’ commitment towards patient safety.
1. United Kingdom of Great Britain and Northern Ireland: Mr Jeremy Hunt, Secretary of State for Health and Social Care WHA resolution on Global Action on Patient Safety, including World Patient Safety Day
Through anecdotal and data driven analyses, Mr. Hunt spoke about the burden of patient safety incidents on family members and the need to use these experiences to introduce effective policy change. Going forward, he stressed the importance of three tasks: to better collect and share data, to focus global attention and more research on patient safety, and to continue to question the culture of modern health care in order to shift from a blaming environment to a learning environment. The only way that we’ll do that [change the culture],” he stressed, “Is if we work together, becoming much more rigorous about spreading best practice.”
2. Germany: Mr Jens Spahn, Federal Minister of Health
The economics of patient safety and Bonn Summit 2017
Mr. Jens Spahn likewise stressed the importance of focusing on patient safety to maintain trust in the health care system, stating that “We cannot tolerate compromise on patient safety. After all, behind every medical error lies a very personal history of suffering.” Acknowledging that “Without patient safety, there can be no universal coverage,” Mr. Spahn further stated that in order to be successful, transparency, visible leadership and blame free patient safety culture are needed. The German Minister continued by stating that the return on investment, or economic gains from improving patient safety, is much higher than in other health care sectors, particularly powerful in low and middle-income countries (LMICs), therefore making patient safety a valuable area to improve. Germany also suggested the establishment of a World Patient Safety Day following the Bonn Summit in 2017.
3. Japan: Dr Yasuhiro Suzuki, Vice-Minister for Health, Chief Medical and Global Health Officer, Ministry of Health, Labour and Welfare
Tokyo Declaration on Patient Safety 2018 and experience of Japan
Dr Yasuhiro Suzuki had led the discussions on developing a patient-centered approach following the 2018 Tokyo Declaration on Patient Safety, which urged Member States to “pay the closest possible attention to the problem of patient safety and establish and strengthen science-based systems, necessary for improving patient safety and the quality of health-care.” Using past malpractice data and following the key map introduced in 2005, Japan advocated patient empowerment, creation of a no-blame culture, manufacturer misuse proof, and government and hospital incident reporting system in order to reduce the number of avoidable patient safety incidents each year. Dr Suzuki also advocated for early installation of patient safety measures and systems into early stage health systems, as it is much more efficient and cost effective than waiting to establish these measures into established health systems.
4. Saudi Arabia: Dr Abdulelah Alhawsawi, Director -General, Saudi Patient Safety Center Implementing the WHO Global Patient Safety Challenge: Medication Without Harm
Dr Abdulelah Alhawsawi presented national initiatives in Saudi Arabia in multiple areas and in collaboration with multiple organizations to improve patient and medication safety, including working on antimicrobial resistance. This included creation of the Saudi Patient Safety Center, development and implementation of Essential Safety Standards (ESRs) through the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI), the national licensing and accreditation agency, in order to annually screen hospitals for over 20 indicators of patient safety and management, including medication safety. The medication safety initiatives also included measures such as community pharmacy certification, tips and alerts, online courses, and patient safety officers training. In his concluding remarks, Dr Alhawsawi invited all attendees to the 4th Global Ministerial Summit on Patient Safety to be held in Saudi Arabia in March 2019.
5. Kenya: Dr Jackson Kioko, Director of Medical Services, Ministry of Health Linking patient safety to UHC and the SDGs
Dr Jackson Kioko emphasized “quality of the highest standards” as “a significant investment and an essential foundation for health,” when scaling up accessibility to care in coordination with achieving UHC. Linking patient safety to UHC and the Sustainable Development Goals (SDGs), Dr Kioko spoke about multi-tiered regulatory structures and centers in Kenya to promote and maintain high standards of quality of care, including professional development, patient safety standards and norms on infrastructure, and leadership and governance. Institutionalizing health service delivery remains a priority for Kenya to support sustainability for patient safety measures.
6. Poland: Mr Zbigniew Czech, Ambassador, Permanent Mission of Poland to the United Nations (on behalf of Mr Marcin Czech, Deputy Minister of Health)
The value of international co-operation, and international and regional patient safety networks
The level of patient safety determines the effectiveness of the healthcare system, as stated by Mr Zbigniew Czech, in his address on the value of international co-operation and international and regional patient safety networks. Mr Czech emphasized the importance of national, regional, and international cooperation to exchange views, experiences, build networks, and improve access and affordability to medical practice. Acknowledging the WHO Global Patient Safety Challenge: Medication Without Harm, Mr Czech mentioned the importance of collaboration with WHO to continue to create momentum and enhance international networking. One such example included the Performance Assessment Tool for quality improvement in Hospitals (PATH) initiative in collaboration with WHO to improve patient care.
The Center for Quality Assessment in Health care in Poland is tasked with “improving patient safety and quality of services, as well as patient empowerment within the context of universal health coverage,” and uses the tools developed through collaboration and networking to achieve higher standards of patient care, health literacy, and self-care.
7. South Africa: Ms Lebogang Lebese, Ministry of Health (on behalf of Ms Precious Matsoso, Director-General of Health, Ministry of Health)
Embedding quality in health care for patient safety
Ms Lebogang Lebese addressed the audience by sharing South Africa’s approach on patient safety by linking improvements in patient safety to improvements in overall quality of care in South Africa. Ms Lebese shared three recent policies put in place, including the National Guideline for Incident Reporting and Learning, conducting surveys for patient experience of care, and frameworks for managing complaints, compliments, and suggestions. These were aimed to get feedback from the users on services, as well as begin to change the culture of health professionals away from blame, towards learning. The norms and regulations that South Africa has implemented and plan to implement are in line with the constitutional promise to citizens to provide high quality, sustainable, “ideal” facilities, care and experiences.
8. Denmark: Dr Søren Brostrøm, Director-General, The National Health Authority Patient safety in a universal perspective – from hospital to primary health care
Recognizing that patient safety is a shared responsibility of multiple different levels and nuances, Dr Brostrøm proposed an open and transparent approach towards improving patient safety in which learning from one's mistakes is the primary focus. Besides requiring licensed health professionals to report all patient safety incidents, primary care requirements were also updated to extend these standards to all levels and forms of care. The value and success of this system in Denmark is owed to the policies protecting professionals from sanctions and financial drivers seeking to take advantage of mistakes. Speaking of the importance of maintain a level of trust between health care professionals, the government, and patients, Dr Brostrøm cited the commitment, high compliance, and follow up by local patient safety officers as key towards the improvement of patient safety in Denmark. Denmark addressed the Medication without Harm campaign as a priority to implement and support alongside other countries, citing the need for continued support from WHO to implement these changes.
9. Sri Lanka: Dr Rajitha Senaratne, Minister of Health, Nutrition and Indigenous Medicine Patient safety initiatives in Sri Lanka towards achieving UHC
Dr Rajitha Senaratne informed the audience of the 24 clinical indicators Sri Lanka has established in addition to free access to healthcare services in order to improve patient safety.
Methods included group training programmes, monitoring and evaluating mechanisms and mobilizing human resource capabilities to improve patient experience and patient responsiveness for feedback purposes via digitalization of healthcare institutions. Dr Senaratne concluded by reminding the audience of the importance of “establishing clear policies, organizational leadership capacity, better provided safety improvements, skilled health care provides, and better involvement of patients in their care, which are essential for sustaining and supporting significant improvements in the safety of health care.” These steps are important in making patient safety a priority that needs to be addressed.
10. Switzerland: Mr Pascal Strupler, Swiss Secretary of State for Health Affirmation of Global Patient Safety Day and 2020 Patient Safety Summit
Mr Pascal Strupler briefly addressed Swiss collaboration, commitment, and continued momentum on patient safety, particularly with the establishment of a World Patient Safety Day. The address included the affirmation of hosting the 2020 Global Ministerial Patient Safety Summit in Switzerland, as well as the acknowledgement that Switzerland will support the organization of 2021 Summit in a LMIC.
Discussion
A moderated discussion took place after the Member States’ presentations, which included a variety of interventions, comments and questions to the panelists. Among those were representatives from the International Pharmaceutical Federation (FIP) who pledged their continued support towards the patient safety by increasing the number and training of pharmacists worldwide. Representative from the World Medical Association for Junior Doctors asked how patient safety might tackle the low morale of doctors. Other interventions included addressing thrombosis, the leading causing of disability adjusted life years and largest preventable injury once entering a hospital, by the International Society of Thrombosis and Haemostasis. Further discussion points included addressing water and basic infrastructure and sanitation needs as well as health care-associated infections. Comments were made addressing upcoming events and goals aimed at educating the new generation on patient safety. Finally, panelists were urged to recognize that measuring patient safety is not simply about measuring death but more generally accounting disabilities and medication related complications.
Summary and Conclusions
The panel closed with remarks made by Professor Bruce Keogh, former National Health Service Medical Director for the United Kingdom, on behalf of Mr Jeremy Hunt. By collectively collaborating to examine the burden and implication of avoidable events that negatively harm patients, countries can improve patient safety and quality of care in the future. Dr Keogh concluded the event by stating that the biggest mistake we can make is to not face up and learn from our mistakes to improve care in the future, echoing the sentiments of many representatives to shift the culture in the health care environment to encourage learning and collaboration in order to achieve UHC and the SDGs.
The objective of the side event was to emphasize the urgent need of improving patient safety for the achievement of effective UHC and to review the scope and magnitude of the challenges for patient safety globally. The event served as a platform for discussion to learn from countries’ experiences, strengthen capabilities through international collaboration and learning; and explore policy options and priorities for patient safety and efficiency of health care systems while progressing towards UHC.
A panel composed of ministers of health and high-level officials shared their country experiences and recognized patient safety as a fundamental requirement of all service delivery systems, essential to achieve UHC and its impact in reducing costs and improving efficiency. The panelists highlighted that concerted action was required by countries in implementing the WHO Global Patient Safety Challenge: Medication Without Harm to address significant patient harm due to medication errors and unsafe medication practices.
Stronger political momentum and international collaboration for the global patient safety movement was evident through the endorsement of World Patient Safety Day 17 September as an annual event; commitment to organize annual ministerial summits building on to the success of UK, Germany and Japan Summits since 2016, and future summits to be organized by Saudi Arabia (2019) and Switzerland (2020); and an urgent call for “Global Action on Patient Safety”.
Results
- High-level political commitment for prioritizing patient safety to strengthen health care systems and achieve effective UHC; and recognition of the impact of patient safety in reducing costs and improving efficiency.
- Stronger collaboration for the global patient safety movement, including a proposal for a WHA resolution on Global Action on Patient Safety, the establishment of World Patient Safety Day, the organization of a series of annual ministerial summits, and a Global Patient Safety Collaborative, with emphasis on the needs of LMICs.
- Concerted action in implementing the WHO Global Patient Safety Challenge: Medication Without Harm to address significant patient harm due to medication errors and unsafe medication practices.
Acknowledgements
Saudi Arabia Team
- Dr Abdulelah Alhawsawi, Director-General, Saudi Patient Safety Center, Riyadh
- Dr Abeer Muhanna, Medication Safety Team Leader, Saudi Patient Safety Center, Riyadh
- Mr Saud Alsaati, Health Attaché, Saudi Mission to the UN, Geneva
Japan Team
- Dr Kiwamu Nagoshi, Director of Medical Safety Promotion Office, Health Policy Bureau
- Ministry of Health, Labour and Welfare
- Ms Ogusa Shibata, Deputy Director for Medical Safety, the Medical Safety Promotion Team
- Office, Health Policy Bureau, Ministry of Health, Labour & Welfare, Tokyo
- Dr Miyako Otsuka, Unit Chief, Medical Safety Promotion Unit Office, Health Policy Bureau,
- Ministry of Health, Labour and Welfare, Tokyo
- Dr Kiwamu Nagoshi, Director of Medical Safety Measures Office, Health Policy Bureau,
- Ministry of Health, Labour and Welfare
- Mr Hideaki Nishizawa, Health Attaché, Japan Mission to the UN, Geneva
Germany team
- Dr Ingo Härtel, Deputy Head, Unit 317 – Health law, patient rights, patient safety, German
- Federal Ministry of Health, Berlin
- Dr Rainer Sbrzesny, Speaker, Unit 317 – Health law, patient rights, patient safety, German
- Federal Ministry of Health, Berlin
- Ms Corinna Huelnhagen, Health Attaché, German Mission to the UN, Geneva
UK Team:
- Mr Stephen Rippon, Patient Safety, Quality and Investigations Team, UK Department of Health and Social Care, Leeds
- Dr Shaleel Kesavan, Patient Safety, Quality and Investigations Team, UK Department of
- Health and Social Care, Leeds
- Dr Andrew Buckley, Patient Safety, Quality and Investigations Team, UK Department of Health and Social Care, Leeds
- Ms Debs Berry, Head of the Health Team, UK Mission to the UN, Geneva
WHO Team:
- Dr Neelam Dhingra-Kumar, Coordinator, Patient Safety and Risk Management Unit, WHO Geneva
- Dr Edward Kelley, Director, Service Delivery and Safety Department, WHO Geneva