The first global experts’ consultation for the development of the WHO Leaders Guide on Patient Safety and Quality of Care in Service Delivery took place at WHO HQ in Geneva Switzerland, 20-21 March 2014.

A draft Leadership Competencies Framework on Patient Safety and Quality of Care has been developed by WHO through a literature search and analysis of findings.

This video was produced for use in a seminar or workshop setting in conjunction with the Learning from Error booklet. The booklet explains more about how the resource can be used to facilitate learning for health care professionals.

Chapter 1 provides an introduction to the concept of root cause analysis. Chapter 2 is a dramatized incident of how a series of errors led to the incorrect administration of vincristine. Chapters 3-8 analyse the drama in the light of five factors that can reduce error in health care.

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Core competencies to carry out patient safety research

This list of core competencies outlines the skills, knowledge and attitudes needed to conduct patient safety research. By strengthening heath professional’s capacity to improve patient safety research and measurement, leaders can drive improvements and influence progress in achieving safer care.

This document is targeted towards policy makers, researchers, health professionals and managers interested in patient safety research. It is also useful for course organizers and trainers that develop curricula or organize training programmes.

• List of core competencies to carry out patient safety research

The development process involved identifying an initial framework for the competencies, reviewing the relevant literature, conducting consultations with potential users and international experts and convening a global consensus conference. The working group report below provides more details about the core competencies and the development process.

• Development of the core competencies for patient safety research
  Expert working group report, July 2010

Related links

• Article: Core competencies for patient safety research: a cornerstone for global capacity strengthening
  BMJ Qual Saf 2011;20:96e101

Classic studies in patient safety research

A series of lectures based on classic research studies

This section presents a series of lectures using examples of research studies in each of the key areas to stimulate new research and debate in patient safety research.

These cases are arranged around the research cycle:

1. Measuring harm

Measuring what goes wrong in health-care involves counting how many patients are harmed or killed each year, and from which types of adverse events.

Find five presentations below on selected published studies exploring different methods for measuring harm.

• Retrospective chart review
  Based on a Canadian adverse events study that investigated the incidence of adverse events among hospital patients in Canada (2004)
• Direct observation mixed methods approach
  Based on a study that looked at the nature and causes of human errors in the intensive care unit (2003)
• Malpractice claims analysis
  Based on a study of closed malpractice claims for missed and delayed diagnoses in the ambulatory setting (2006)
• Mixed methods approach
  Based on a study that compared three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals (2004)
• Prospective cohort study
  Based on a study that assessed the incidence of and risk factors for surgical-site infections in a Peruvian hospital (2005)

2. Understanding causes

Due to the complex nature of health-care, there is no single reason why things go wrong. Research is therefore needed to identify the major underlying causes of adverse events that lead to patient harm.

Find four presentations below on selected published studies that use various methods to explore the underlying causes of certain adverse events.

• Cross-sectional study
  Based on a hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction study
• Prospective ethnographic study
  Based on an alternative strategy for studying adverse events in medical care
• Prospective cohort study
  Based on a comparative study of intensive care and general care units for preventable adverse drug events in hospitalized patients
• Cross-sectional study
  Based on a study that investigated how house officers learnt from mistakes

3. Identifying solutions

To improve patient safety we need to conduct research to determine which solutions are effective in making care safer and reducing patient harm, compared to the standard of care.

Find five presentations below on selected published studies that evaluate various solutions to certain patient safety incidents.

• Randomized control trial
  Based on a study evaluating the impact of dedicated medication nurses on the medication administration error rate (2003)
• Cluster randomized clinical trial
  Based on a study of the medical emergency team (MET) system (2005)
• Cluster randomized clinical trial
  Based on a study that evaluated the effects of teamwork training on adverse outcomes and process of care in labor and delivery (2007)
• Prospective intervention study
  Based on a study of an intervention to decrease catheter-related bloodstream infections in the ICU (2006)
• Randomized clinical trial
  Based on a study of antibiotic prophylaxis for general and gynaecological surgery from a single centre in rural Africa (1996)

4. Evaluating impact

Even when solutions have been shown to work in controlled research settings, it is important to evaluate the effectiveness of solutions in real-life settings including their impact, acceptability and affordability.
Find two presentations below on selected published studies that use various methods to evaluate the effectiveness of solutions to certain adverse events.

• Cost analysis
  Based on a study that analyzed the costs of adverse drug events in hospitalized patients (1997)
• Cost identification analysis
  Based on an a study that estimated the cost of nosocomial infection in Turkey using data from a university hospital (2001)

5. Translating evidence into safer care

The final step in the research cycle is to better understand how research findings can be translated into practice. This is especially important in developing countries and transitional economies, where resources are scarce and research infrastructures are often limited.

Find one presentation below that reviewed and assessed different techniques of analysis pf critical incidents and adverse events, as well as how these techniques can benefit the development of guidance for safer care.

• Health technology assessment review
  Based on an investigation and analysis of critical incidents and adverse events in healthcare (2005)