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  • Patient Safety Learning: How do we take global action for patient safety? (15 October 2020)

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    Summary

    In this blog, Patient Safety Learning considers the need for global action to improve patient safety and sets out its response to the WHO’s consultation on the draft Global Patient Safety Action Plan 2021-2030.

    Content

    In May 2019, the World Health Assembly recognised patient safety as a key health priority, acknowledging the need to “take concerted action to reduce patient harm in healthcare settings”.[1] They asked the World Health Organization (WHO) to formulate an action plan to help improve patient safety, resulting in the first draft Global Patient Safety Action Plan 2021-2030, published for consultation in August 2020.[2]

    Patient Safety Learning is pleased to have contributed to the development of this global initiative, with our Chief Executive, Helen Hughes, having attended the initial consultation sessions earlier this year.[3] [4] At the end of September, we responded to the WHO with our feedback on the first draft. Here is a summary of that feedback.

    The WHO Global Patient Safety Action Plan

    Patient safety is an issue which impacts all countries, with the WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide.[5] In high income countries, as many as one in 10 patients are harmed while receiving hospital care.[5] In low- and middle-income countries, the impact is even greater, with poor quality care estimated at accounting for 10-15% of total deaths, some 2.6 million deaths annually.[6]

    We welcome, therefore, the WHO’s focus on patient safety as a global priority, along with its vision of a “world in which no patient is harmed in health care, and everyone receives safe and respectful care, every time, everywhere”.[2] It sets out its goal as achieving the maximum possible reduction in avoidable harm as a result of unsafe care.[2] To help achieve this goal, the Action Plan outlines a set of guiding principles:

    1. Treat patients and families as partners in safe care.
    2. Achieve results through collaborative working.
    3. Analyse data and experiences to generate learning.
    4. Translate evidence into measurable improvement.
    5. Base policies and action on the nature of the care setting.
    6. Use both scientific expertise and stories of care to educate and advocate.

    These principles closely align with our six foundations for safe care that are needed to progress towards a patient-safe future, as we argue in our evidence-based report A Blueprint for Action.[7]

    The Action Plan subsequently goes on to outline seven strategic objectives which provide a framework for achieving its goal. Each objective is underpinned by specific strategies with accompanying actions for the WHO, governments, healthcare organisations and key stakeholders.

    Tackling the implementation gap and sharing learning

     A key issue that the Action Plan identifies as a barrier to making patient safety improvements is what it describes as the “knowing-doing” gap, known elsewhere as the “implementation gap”.[8]

    There are many examples where a team, organisation or even country may be implementing patient safety solutions, but this good practice or successful measure is siloed within that team, organisation, or country. Patients will then continue to experience harm from problems, despite successful solutions already in existence elsewhere.

    At Patient Safety Learning, we see the shared learning for patient safety as a vital means of tackling this ‘knowing-doing’ gap. We feel that the Action Plan could place a stronger emphasis on shared learning more widely, both by the WHO and between member states, stressing the importance of disseminating good practice and patient safety knowledge. As an example, where the WHO proposes that governments should publish an independently audited annual report on patient safety performance, we believe an additional action is needed, specifically that the WHO should collate these national reports and share their findings on annual basis. There would be huge value in seeing what progress member states are making and this would support active networking and collaboration.

    We are helping to tackle the knowing-doing gap with the hub, our platform to share learning for patient safety. We would be happy to share our experience and collaborate with the WHO in sharing learning to improve patient safety.

    Building high reliability health systems and organisations

    The Action Plan notes that a key safety success factor in other high-risk industries is “the emphasis placed on preventing accidents, harm and mistakes that have serious consequences”.[2] Related to this it sets a strategic objective focused on the creation of High Reliability Organisations in health, that are able to operate in complex circumstances where there are significant risks without serious accidents or catastrophic failures.[9] Such organisations “cultivate resilience by relentlessly prioritising safety over other performance pressures”.[9]

    We strongly agree with this approach, which aligns with our belief that patient safety should not simply be another priority but part of the purpose of health and social care. In our feedback, we noted that it is vital to also account for the role of Health IT (HIT) systems in making patient safety core to health and social care. Failure to do so can, under certain conditions, lead to patient harm. In the design, development and use of new technologies, patient safety should be embedded into all stages of the process, helping to reduce errors in healthcare and ultimately saving lives.

    We made the case in our feedback that the Action Plan should include guidance around the use of healthcare technology assessment and safety risk management when making decisions about the use of new IT systems.[10] This guidance would need to include steps to ensure that organisations have specific safety guidelines and tools for the use of HIT, and publicly available examples of HIT safety cases. Included in these steps should be the assessment of patient safety risks when introducing any changes, whether technology, operational or process changes.

    Working with partners to bring about change

     The Action Plan rightly emphasises the importance of working with stakeholders - beyond those charged with the delivery of health and social care - to improve patient safety and staff safety. We believe the following groups should also be considered as essential partners:

    •  Trade Unions - bodies that represent health workers have a key role to play if we are to ensure that patient safety considerations are at the core of healthcare. Ensuring the safety of health workers is intrinsically linked to making improvements to patient safety.[11]
    • Human Factors/Ergonomics professionals - collaboration with these individuals will be particularly important in making the changes needed, as set out in the Action Plan’s Strategic Objective 2, to build high reliability health systems. Included in this group should be both experts in this area working in healthcare and those from other industries who are able to contribute their experiences and expertise.
    • International Development organisations - the relationship between international development and patent safety is an underexplored area, worthy of further work. As such, we believe that Non-Governmental Organisations involved in development work should also be included on the stakeholders list.

    How do we create a global patient safety movement?

     Much of the focus of the Action Plan understandably centres on work that can be done by governments, healthcare organisations and the WHO to improve patient safety. To achieve the scale of change needed, however, Patient Safety Learning believes we also need to develop and support a social movement for patient safety.

    In early initial discussions about the Action Plan, Sir Liam Donaldson, WHO Envoy for Patient Safety, noted this, emphasising the value and impact of mobilising public pressure to deliver change. He also deemed it essential that we learn from past campaigns that have succeeded.[3]

    How do we start such a social movement? It is a difficult question, but we believe a key consideration is the democratisation of healthcare systems and the role of co-production with patients. This will mean overcoming some of the fears that exist around working in equal partnership with patients and avoiding the trap where patients can become ‘insiders’. Patients, families and carers need to be an effective independent voice for change.

    References

    1.    WHO, World Health Assembly Update, 25 May 2019.

    2.    WHO, Global Patient Safety Action Plan 2021-2030, 28 August 2020.

    3.    Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 1, 6 March 2020.

    4.    Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 2, 16 March 2020.

    5.    WHO, Patient Safety Fact File, September 2019.

    6.    National Academies of Sciences, Engineering and Medicine, Crossing the Global Quality Chasm: Improving Health Care Worldwide, 2018.

    7.    Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019.

    8.    Suzette Woodward, Patient safety: closing the implementation gap, 30 August 2016.

    9.    Agency for Healthcare Research and Quality - Patient Safety Network, High Reliability, 7 September 2019.

    10. Health technology assessment (HTA) refers to the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform a policy decision making. WHO, Medical devices: Healthcare technology assessment, Last Accessed 13 October 2020.

    11. Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020

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    Dear Helen Hughes CE.

    Please find enclosed pdf "Ward patient safety solution: An eQMS with Alarmed Error Recovery Protocols."

    It is one hell of a technique, Steve Turner gives it the thumbs up too.

    This is the global silver bullet you and PSL have been waiting for.

    If there is anything you do not understand please contact me.

    Kind Regards

    Derek.

     

     

    Ward-Patient Safety Solution. An eQMS with Alarmed Error RecoveryProtocols..pdf

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    Hi @Derek Malyon 

    Thank you got this, really interesting. Do you know of any work being taken forward in this area? 

    This approach would not only provide a feedback loop that would highlight activity omissions but would place the consenting patient at the heart of decision making. 

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    Dear Helen

    Thank you so much for replying.

    I believe this solution is completely new to healthcare.

    I have contacted countless NHS departments as well as Sir Robert Francis QC, Professor Carl Macrae, Professor C P Gale, the BMJ and WHO. All seem lost. In the U.K. this technique would have saved 33,000 heart attack and 60,000 bedside life-sign patients in a 10-year period.

    Please can the hub help me find an NHS Department who will pickup this patient safety eQMS. Perhaps Dr Abdulelah Alhawsawi would be interested? (I have no connection with the NHS at all.)

    Many Thanks

    Derek.

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    Hi Derek,

    You describe a frustrating and lonely path for innovation. @Clive Flashman any suggestions of where Derek could promote this approach?

    Helen

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    @Derek Malyon and @HelenH
    the typical route for innovation to enter the NHS is via the 15 regional Academic & Health Science Networks. Depending on where you are based Derek, you should make enquiries of your local AHSN to see if they can help you to promote your ideas into the NHS. If you have already tried that route then I'd be interested to hear what happened.

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    Hi Clive

    Thank you very much for the information. I contacted the SW AHSN Tuesday 11.2.2020. Here is a copy sent sent now.

    Hello AHSN
    I contacted you in Feb 2020 but received no reply.
    Clive Flashman of the Patient Safety Learning hub suggests I contact you.
    I wish to send you a pdf (1.7 Mbit): Ward-Patient Safety Solution: An eQMS with Alarmed Error Recovery Protocols.
     
    This ward-patient tagged quality system reduces healthcare worker HE consequences by a factor of 10,000. It is a derivative of industrial H&S and the Banking sectors.

    Kind Regards
    Derek.

    -------------------------------------------------------

    Thank you Clive.

    Kind Regards

    Derek (Torquay. Devon.)

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    Hi @Derek Malyon
    I think you need to give them a bit more info, for example:
    1. Eliminate the acronyms
    2. What is the purpose of the solution (in more detail)
    3. Is it only for use in hospital on wards, or elsewhere?
    4. Has it already been trialled in the NHS or elsewhere? If so, what were the results?
    5. Have there been any academic evaluations of impact?
    6. Why is it different/ better to what is already being used in the NHS?
    7. How cost-effective is it?
    8. the ASK - what do you want from them? What do you want them to do?

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    Hi Clive

    Thank you for eight good questions. I think the 311 word body in the pdf answers some of these (Qu.2, 6). It is purposely brief admittedly.

    Qu.3 Since the patient must be conscious and capable of understanding yes and no obviously the solution is not suitable for maternity, young children and the operating theatre. However, these patients can have a substitute tag from two different health workers. HE consequences reduced only by a factor of 1000 (Ref. 2a in download.). Steve Turner (community nurse) also sees possibilities too.

    QU.4, 5, 6 7. I believe "An eQMS with Alarmed Error Recovery Protocols"  is a first in global healthcare but common in banking and parcel delivery where the customer is placed in a computerised quality loop. If we kill the AE's as this system can, and not 2.6M patients globally, cost savings are humungous Ref.1 in the download.

    QU.8 Our NHS should assess this eQMS with a view to trialling it.

    Thank you Clive for allowing me a platform.

    Derek.

    Ward-Patient Safety Solution. An eQMS with Alarmed Error RecoveryProtocols..pdf

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    My pleasure @Derek Malyon

    In the new year, I suggest you link up with your local AHSN, and have a conversation with them before sending your PDF with a covering email. I think the 'ask' needs to be as clear as possible. You would like them to trial the eQMS on x wards with y patients for z months, and then explain how the impact will be independently evaluated at the end of that.

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    Good evening Clive.

    Thank you for the information. I have already contacted AHSN via their website with limited word count and directly to their email address with pdf receiving their auto reply.

    Because the NHS culture is slow to change this eQMS derived from Industrial H&S and banking sectors will be a shock and problematic for William Lilley. So, I have decided to send William a copy to digest for Christmas entertainment. Ho Ho Ho.

    The first objective is that AHSN fully understand the concept of an "eQMS with an Alarmed Error Recovery Protocol". This is crucial. If they wish to progress the idea perhaps they should choose how to implement the trial. I have no healthcare experience what so ever.

    I appreciate your interest Clive.

    Kind Regards

    Derek

     

     

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    Hi Clive.

    I have contacted southwest academic health safety network (swahsn) with the above pdf "Ward-Patient Safety Solution: An eQMS with Alarmed Error Recovery." Their front desk staff cannot draw a response from their directors for innovation or patient safety. I have also contacted WL by email  18/12/20, 7/1/21 and left a telephone message but receive no reply from him either.

    ------------------------------------------------------------------------------------------------------------

    Good News: The reference below  (1) describes a similar healthcare quality control detecting medicine error with alarms at the point of delivery to the patient. Sadly, the reduction in medical error is small in comparison to the maximum achievable (10,000) but this paper from an American emergency department in 2013 is noteworthy because it aligns with the classic Industrial H&S error recovery protocol with compelling alarm described and referenced above. 

                                             -----------------------------------------------

    So, by simply adding patient tagged acknowledgement to every intervention on the MDT software checklist be it medicine, biopsy count, bloods, vital life sign, reports or advice etc, it protects patient from error across every department. 

    Reference:

    (1)   Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors: J. Bonkowski et al. AEM Vol. 20.8: p801-806: 2013. (Method: p802, 2nd column, "Medication administration with BCMA................. an alert notified the nurse of a potential for error."(110 words).

    Thank you.

    Kindest Regards

    Derek.

     

     
     
     
     
     
     
     
     
    Thank you.
     
    Kindest regards
    Derek.
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    Hi @Derek Malyon
    sorry that you didn't get more traction from the AHSN, it's a tricky time at the moment but there is no excuse for being unresponsive like that. If I can think of another 'way in' I'll let you know.
    Kind regards, Clive

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    Dear Helen Hughes, Steve Turner and Clive Flashman.

    Re: Patient Safety QMS with Alarmed Error Recovery.

    Method: The patient uses their wristband barcode to acknowledge every intervention against their MDT software checklist.

    Except for CQC and Sir Robert Francis, most NHS front offices including digital find excuses and ignore the safety solution not passing the proposal up.

    The Wexner Medical Centre used the technique by comparing the medicine barcode with a software checklist alarming an error in front of nurse. A reduction in errors was achieved.

    Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors: J. Bonkowski et al. AEM Vol. 20.8: p801-806: 2013. (Method: page 802, 2nd column, "Medication administration with BCMA................. an alert notified the nurse of a potential for error".

    https://onlinelibrary.wiley.com/doi/epdf/10.1111/acem.12189

    So, the latest rejection by AHSN and HSIB's deputy medical director is unbelievable.

    Any business in any other Sector which kills a worker, customer (patient) or member of the public face corporate manslaughter charges by the Police and Crown Prosecution Service here in the UK. The HSIB deputy medical director needs to reconsider their position and apologise.

    Police Operation-Magenta with 100 detectives is the 4th attempt to investigate 450 opioid overdose deaths at GWMH. They need our help desperately. The global healthcare Sector essentially have no error recovery protocol on wards. This is the primary cause of 2.6-4.8 million unnecessary deaths globally and an annual pandemic. Managers who do not respond to this classic industrial H&S solution will very likely have their collars felt by Police.

    Would PSL be prepared to inform NHS England and other patient safety forums of the solution and promote the Operation Magenta website.

    Thank you so much for your platform.

    Kindest Regards

    Derek.

     

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    Hi Derek,

    It's a pushing water uphill task, at times, as you and we well know. 

    Sharing is not the problem, it's getting people to listen and act that's the challenge. By adding content to the hub, we try hard to bring innovation to people's attention. 

    Any more we can do @Clive Flashman ?

    Helen

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    Dear Helen Hughes, Steve Turner and Clive Flashman.

    Re: Patient Safety QMS with Alarmed Error Recovery.

    Method: The patient uses their wristband barcode to acknowledge every intervention against their MDT software checklist.

    Except for CQC and Sir Robert Francis, most NHS front offices including digital find excuses and ignore the safety solution not passing the proposal up.

    The Wexner Medical Centre used the technique by comparing the medicine barcode with a software checklist alarming an error in front of nurse. A reduction in errors was achieved.

    Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors: J. Bonkowski et al. AEM Vol. 20.8: p801-806: 2013. (Method: page 802, 2nd column, "Medication administration with BCMA................. an alert notified the nurse of a potential for error".

    https://onlinelibrary.wiley.com/doi/epdf/10.1111/acem.12189

    So, the latest rejection by AHSN and HSIB's deputy medical director is unbelievable.

    Any business in any other Sector which kills a worker, customer (patient) or member of the public face corporate manslaughter charges by the Police and Crown Prosecution Service here in the UK. The HSIB deputy medical director needs to reconsider their position and apologise.

    Police Operation-Magenta with 100 detectives is the 4th attempt to investigate 450 opioid overdose deaths at GWMH. They need our help desperately. The global healthcare Sector essentially have no error recovery protocol on wards. This is the primary cause of 2.6-4.8 million unnecessary deaths globally and an annual pandemic. Managers who do not respond to this classic industrial H&S solution will very likely have their collars felt by Police.

    Would PSL be prepared to inform NHS England and other patient safety forums of the solution and promote the Operation Magenta website.

    Thank you so much for your platform.

    Kindest Regards

    Derek.

     

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