Patient Safety Learning: Reflections on the latest draft Global Patient Safety Action Plan

Summary

The World Health Organization (WHO) has recently published, for consultation, the third draft of its Global Patient Safety Action Plan 2021-2030. In this blog, Patient Safety Learning reflects on areas where our initial feedback in September 2019 has been incorporated into the new draft and where we believe the Action Plan can be further strengthened

Content

In August last year, WHO published the first draft Global Patient Safety Action Plan 2021-2030.[1] It outlined the scale of the patient safety challenge we face globally, with WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide.[2] The Action Plan set out a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care, accompanied by actions required from WHO, governments, healthcare organisations and key stakeholders over 2021-2030 to help achieve this.

We responded to WHO with our feedback.[3] As part of its ongoing consultation, WHO has now shared a third draft of the Global Patient Safety Action Plan.[4] In this update, we reflect on areas where our feedback has been incorporated and where we feel that there is still room for improvement.

Positive changes to the latest draft

There have been several changes made during the consultation process, based on feedback from a range of different global stakeholders. We are pleased to see the following points incorporated into the latest version:

• In our initial response, we recommended that bodies such as trade unions should be added to the Action Plan’s list of essential partners, to recognise the important link between the safety of health workers and improvements in patient safety. This new draft now includes “Trade unions and other labour organizations representing health workers” as stakeholders.
• We suggested that the relationship between international development and patient safety was an underexplored area and, as such, non-governmental organisations involved in development work should be included as essential partners. The new draft now includes “Development partners, donors and funding agencies” as stakeholders.
• We made the case that there should be stronger emphasis on shared learning between member states. We were pleased therefore to see increased references in the Action Plan to member states working collaboratively “to promote, prioritize and embed patient safety in all health policies and strategies”. However, as we shall touch on subsequently, we believe further improvements could be made.

Where the Action Plan can be strengthened

We feel that there are a number of areas where the Action Plan could be strengthened:

1.    Human Factors/ergonomics; High Reliability Systems

Human factors/ergonomics is identified as a key element of the Action Plan’s second strategic objective to build high reliability systems. We reiterate our initial recommendation that experts in this area, both those working in healthcare and those from other industries who are able to contribute their experiences and expertise, should be included on the list of the Action Plan’s essential partners.

2.    Sharing learning

At Patient Safety Learning, we believe that sharing learning is key to improving patient safety, identifying this as one of our six foundations of safe care in our evidence-based report A Blueprint for Action.[5] In our initial consultation response, we said that we felt the Action Plan should place a stronger emphasis on shared learning, both by the WHO and between member states, highlighting the importance of disseminating good practice and patient safety knowledge.

We restate our suggestion that member states should be asked to share their annual reports on their patient safety performance and that the WHO should collate these and share their findings on an annual basis. We believe there is real value in seeing what progress member states are making and that this would help support active networking and collaboration.

We also consider it essential for all member states to have the means to share knowledge for improving patient safety, including the outcome of incident reporting systems and investigations into adverse events and good practice improvements. We believe that all members states should share such knowledge within their healthcare systems and globally. The WHO may wish to take an active role in this and/or collaborate with national agencies and not-for-profit organisations to promote sharing of knowledge.

the hub is accessed by 177 countries. We welcome collaboration with WHO and member states to strengthen this global knowledge-sharing for safer care.

3.    Healthcare Information (HIT) System

We also made the case in our feedback that the Action Plan should include guidance around the healthcare technology assessment and safety risk management when making decisions about the use of new IT systems.[6]

We do not feel this issue has been sufficiently covered by the latest draft. We believe there needs to be additional guidance 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. Member states need to be supported in how to achieve these aims; without such knowledge and resources, the WHO will struggle to close the “knowing-doing” gap on this essential issue.

4.    Tackling the implementation gap

A major barrier to improving patient safety is what has been termed as the ‘implementation gap’ between learning and taking practical action.[7] While we may know what improves patient safety, this information can often remain siloed in specific organisations or countries, resulting in patients continuing to experience harm from problems that have already been addressed elsewhere.

The Action Plan recognises this issue, describing it as the ‘'knowing-doing" gap. However, we believe there needs to be clearer actions addressing this issue. We are helping to tackle the knowing-doing gap with the hub, our platform to share learning for patient safety. We would be delighted to share our experience and collaborate with the WHO in sharing learning to improve patient safety.

Concluding thoughts

We welcome the development of this Action Plan as a clear indication of the WHO’s focus on patient safety as a global priority. Strengthened as we suggest, it can play a significant contribution in providing a clear framework to enable governments, healthcare organisations and patients to improve patient safety.

References

1. WHO. Global Patient Safety Action Plan 2021-2030: First Draft. August 2020.
2.  WHO. Patient Safety Fact File. September 2019.
3.  Patient Safety Learning. How do we take global action for patient safety? 15 October 2020.
4.  WHO. Global Patient Safety Action Plan 2021-2030: Third Draft. January 2021.
5.  Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action. 2019.
6.  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, organisational 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.
7.  Suzette Woodward. Patient safety: closing the implementation gap. 30 August 2016.