World Health Assembly resolution WHA72.6 on “Global action on patient safety” urges World Health Organization (WHO) Member States to promote a safety culture by providing basic training to all health professionals and developing a blame-free patient safety incident reporting culture through open and transparent systems that identify and learn from examining causative and contributing factors of harm.
The Global Patient Safety Action Plan 2021–2030 provides a strategic direction for concrete actions to be taken on patient safety. It prioritizes the establishment of patient safety incident reporting and learning systems under strategic objective 6, on “Information, research and risk management”, which aims to “ensure a constant flow of information and knowledge to drive the mitigation of risk, a reduction in levels of avoidable harm, and improvements in the safety of care”.
The WHO Regional Office for South-East Asia and country office in Maldives received a request to assist the quality assurance team in the Maldives Ministry of Health in training on patient safety incident reporting and learning systems to help achieve a better understanding of their concepts, the role of systems and stakeholders, the mechanisms for data collection and retrieval, and the development of learning components to improve patient safety.
The Ministry of Health has been actively working on patient safety and quality of care, including through:
- establishment of quality assurance standards in 2018, which cover hospital infrastructure and patient safety;
- establishment of a national complaint reporting system whereby complaints from citizens can be sent via email or at facilities and analysed within the reporting framework;
- managing multiple adverse event reporting systems, including in the areas of pharmacovigilance, blood safety, and after immunization.
The WHO Patient Safety Flagship has prepared this first training on patient safety incident reporting and learning systems with the Maldives Ministry of Health, Regional Office for South-East Asia, WHO country office in the Maldives, and international experts. The goals of the training were to provide:
- an overview of patient safety incident reporting and learning systems;
- basic training on collecting and analysing patient safety incidents;
- guidance on how to build a safety culture by utilizing patient safety incident reporting and learning systems.
In establishing the technical areas to be taught in the training, the topics needed to match the level of understanding of the participants. The Ministry of Health accordingly provided information on the background of the participants to help WHO decide the depth of content for each technical area to be included in the training.
The Ministry of Health called for participants from all the hospitals in Maldives to take part in the training. The original plan was to provide Ministry of Health staff with this training; however, the Ministry of Health decided to open the training to wider participation. The ministry received more than 220 nominations from around the country, including from doctors, nurses, and clinical and non-clinical staff.
The training was held on 28–30 March 2022, from 15:00 to 18:00 Maldives time. Four international experts taught the contents that they had developed, based on their experiences with incorporating WHO technical guidance on patient safety incident reporting and learning systems, and following approval by WHO and the Ministry of Health.
Day 1 covered the basic understanding of patient safety, patient safety incidents, and reporting and learning systems. The publication To err is human: building a safer health system (1999) formed an influential basis for the training. In addition, the WHO publication Patient safety incident reporting and learning systems: technical report and guidance (2020) contributed key messages and ideas to update reporting and learning systems. Day 2 introduced governance of and challenges to patient safety incident reporting and learning systems, including their operation, the importance of creating a positive environment for reporting, and patient and family engagement. Day 3 considered the mechanism of the systems, from collection of incident data to retrieval and dissemination of the learning components of the incident reports. The experiences in the establishment of patient safety incident reporting and learning systems in four countries were also shared in the three-day training.
All agreed that a blame-free culture, anonymity of reporting, and leadership were key drivers in encouraging health professionals to report patient incidents. In addition, the importance of patient and family engagement in patient safety incident reporting and learning systems was acknowledged throughout the training.
Ms Thasleema Usman, Commissioner of Quality Assurance at the Maldives Ministry of Health, said that the training was very insightful and covered the range of components that the participants should know. It provided the essentials on how to establish national patient safety incident reporting and learning systems, foster a blame-free culture, and educate leaders on the importance of creating an environment for improving patient safety and quality of care. Ms Usman also called for collaboration with all hospitals in the country in making the next step.
The next training – on the human factors and ergonomic tools for patient safety incidents – was taken place on 19 and 28 April. This training was conducted by the Centre for Clinical Risk Management and Patient Safety, Department of Health of the Tuscany Region in Italy, together with WHO and the Maldives Ministry of Health. The recordings and training materials would be shared on the WHO website following the training.
WHO would continue to provide technical support for the establishment of national patient safety incident reporting and learning systems in Maldives and other countries through the collaboration of the three levels of WHO and other stakeholders, including WHO collaborating centres, non-state actors in official relations with WHO, and international experts.
Training schedule
Day 1
1.1 Introduction to patient safety
Classification of hospital accidents, types of medical errors, elements of safety culture (evolution of patient safety culture, no-blame culture)
1.2 Patient safety incident reporting and learning systems
What are patient safety incident reporting and learning systems? Key definitions and concepts of patient safety incidents, different requirements of different levels of patient safety incident reporting and learning systems (institutional, subnational, national), linkage with International Classification of Diseases, 11th Revision
1.3 Creation of a safe environment for health workers to report patient safety incidents
Understanding of “to err is human”, non-punitive investigation, confidentiality, facilitation of reporting through a no-blame culture, anonymous reporting, rewards
Day 2
2.1 Existing environment for patient safety incident reporting and learning systems
National adverse event systems, existing legal environment
2.2 Operationalization and challenges of patient safety incident reporting and learning systems
Governance and management of patient safety incident reporting and learning systems, staffing, training
2.3 Sri Lanka’s experience
Day 3
3.1 and 3.2 Application of incident reports 1 and 2
Purpose of collecting incident reports, data elements of the report (minimal information model for patient safety), data collection methods, quality assessment of incident reports, the importance of data analysis, data utilization (short-, medium-, and long-term implications), products from patient safety incident reporting and learning systems
3.3 South Africa’s experience
3.4 Thailand’s experience
Patient Safety Incident Analysis workshop schedule
1. Introduction
2. Human factors and ergonomics tools for the analysis of patient safety incidents
3. Reporting and learning systems: methods of analysis and sharing of knowledge
4, Case study: structured analysis adapting method to context
5. Reporting and learning systems: Tools