The onion model assembles the building blocks for independence based on universal human values:

• People want control over their own lives for as long as possible
• People strive to maintain or improve their own quality of life
• People seek social interaction
• People seek ‘warm’ relationships with others.

The professional attunes to the client and their context, taking into account the living environment, the people around the client, a partner or relative at home, and on into the client’s informal network; their  friends, family, neighbours and clubs as well as professionals already known to the client in their formal network.

In this way the professional seeks to build a solution involving the client and their formal and informal networks. Self-management, continuity, building trusting relationships, and building networks in the neighbourhood are all important and logical principles for the teams.

The top-performing countries overall are Norway, the Netherlands, and Australia. The United States ranks last overall, despite spending far more of its gross domestic product on healthcare. The U.S. ranks last on access to care, administrative efficiency, equity, and health care outcomes, but second on measures of care process.

Four features distinguish top performing countries from the United States:

• they provide for universal coverage and remove cost barriers
• they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people
• they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts
• they invest in social services, especially for children and working-age adults.

1. Racial and ethnic disparities in healthcare.
2. Emergency preparedness and response in aging services.
3. Pandemic preparedness across the health system.
4. Supply chain interruptions.
5. Drug shortages.
6. Telehealth workflow challenges.
7. Improvised use of medical devices.
8. Methotrexate therapy.
9. Peripheral vascular harm.
10. Infection risk from aerosol-generating procedures.

35. We affirm that patient safety is a global health priority that deserves urgent attention and concerted action, particularly in the context of the additional strains on health systems as a result of the COVID-19 pandemic. We recognise patient safety as one of the significant cornerstones for achieving UHC and SDGs. The principle of "first do no harm" is a fundamental element to providing quality healthcare and services. We are committed to strengthening the international coordination of initiatives and platforms to improve patient safety through quality of care and people-centered strategies that empower individuals and healthcare professionals, expand the frame of primary healthcare and the role of patients in improving care and engage communities. We are also committed to advancing research to demonstrate the benefits of investing in patient safety interventions that can be implemented in an appropriate and sustainable way. Patient Safety should be emphasized in all types of health care delivery, including the use of digitalization in health services. We are committed to increase patient safety culture awareness with continuous training for all healthcare providers, particularly in primary healthcare.

36. We recognize that patient safety will reinforce the efforts to address health disparities, in particular, promoting the safety of patients in positions of vulnerability, such as mothers, newborns, children, adolescents, elderly patients, persons with disabilities, and those facing emergencies and extreme adversities.

37. With the aim to support the implementation of the resolution adopted by the 72nd World Health Assembly in May 2019, "Global Action on Patient Safety," (WHA 72.6) and the Jeddah and Tokyo Declarations on patient safety, we welcome the establishment of a Global Patient Safety Leaders Group. The purpose of this Group is to bridge implementation gaps through system-level solutions, global shared platforms for reducing patient safety risk and increasing learning, and locally applicable innovative solutions. This can be done by adapting evidence-based practices from high-reliability industries (e.g. aviation, nuclear, gas and oil) and human factors engineering to improve patient experience and engagement as well as enhance workforce training and education in patient safety. Patient safety actions will also support efforts in relation to COVID-19 outbreak and other emerging health care threats, such as addressing risks of nosocomial transmission and unwarranted medication, need for infection prevention and control measures, and protecting healthcare workers from infection, and gearing up for healthcare facilities to provide for healthcare worker safety and meet the required minimum standards for hygiene and infection prevention and control (i.e. UNICEF WASH/ Health program). Accordingly, the Group will promote global advocacy for patient safety.

38. The Group will produce a progress report for the member states and relevant International Organizations. It is comprised of patient safety experts nominated by member and non-member countries, on a voluntary basis. The Group will also have representatives from high-reliability industries and relevant International Organizations.

39. The Group will have one eminent Chairperson who has been a leading voice in the global patient safety agenda and two deputy chairs: one from the World Health Organization and another from the Kingdom of Saudi Arabia. The Group's initial term will be five years with the possibility of renewal based on consensus and recommendations from the members, and, beyond the current year, will continue as an independently

Goals

• Stimulate the development and use of reporting and evaluation systems by individual health care organisations.
• Stimulate reporting to a national system for review, analysis, and development of recommendations to reduce and ultimately prevent medication errors.
• Examine and evaluate the causes of medication errors.
• Increase awareness of medication errors and methods of prevention throughout the health care system.
• Recommend strategies for system modifications, practice standards and guidelines, and changes in packaging and labelling.

Objectives

• Promote reporting, discussion and communication about safe medication use, medication errors and error-prone processes, and error-prevention strategies.
• Develop and broadly disseminate NCC MERP's recommendations and other work products related to reporting, understanding, and prevention of medication errors.
• Collaborate with other interested stakeholders to address special topics related to medication errors and patient safety initiatives.

Strategies

Medication error reporting

• Heighten awareness of reporting systems available to or within health care organisations.
• Stimulate and encourage reporting and sharing of medication errors both nationally and locally.
• Develop standardization of classification systems for the collection of medication error reports so that databases will reflect reports and categorization systems.
• Encourage systems and provide targeted feedback so that appropriate prevention strategies can be developed and implemented in facilities.

Medication error understanding

• Assess current knowledge of medication errors through ongoing efforts (for example, literature searches) to gather data associated with the scope of problems, types of errors, causes and sources of errors, and clinical and financial impact on patients and the healthcare delivery system.
• Identify gaps in research that hinder the understanding of medication errors.
• Promote research to expand knowledge regarding medication errors, their causes, and the effectiveness of interventions

Medication error prevention

• Encourage standardisation of processes to prevent error-prone aspects of drug procurement, prescribing, dispensing, administration, disposal.
• Encourage shared accountability and systems-based solutions to enhance the safety of medication use and to minimise the potential for human error.
• Promote/encourage the safe use and understanding of technology in the prevention of medication errors.
• Increase awareness of the need for distinctive packaging, labeling, and nomenclature of products associated with actual or potential medication errors.
• Educate consumers and patients regarding strategies to prevent medication errors for both prescription and nonprescription medications.
• Educate health care professionals about causes of medication errors and strategies for prevention.

1. To consider recommendations made by the State Coroner and by independent reviews conducted in response to the Chemotherapy Underdosing that relate to incident reporting and management.

2. To determine and describe how the SLS is used across SA Health for patient incident reporting and management including:

a. adoption and uptake;

b. data extraction;

c. reporting;

d. incident management; and

e. open disclosure to patients and feedback to staff.

3. To identify factors that are impeding or may impede the use of SLS, including;

a. the culture of reporting and incident management, and

b. the availability and uptake of training and education. 

4. To determine if Datix Web, the software platform used for the SLS, meets the needs of SA Health and whether its functionality is comparable to alternative programs.

5. To make recommendation to the Chief Executive (CE), Department of Health and Wellbeing that will assist in assuring robust incident reporting and management and the sharing of learnings across SA Health.

• ambulatory healthcare 
• behavioural healthcare 
• critical access hospital 
• home care
• hospital 
• laboratory 
• nursing care centre
• office-based surgery.