World Patient Safety Day 2024

Summary

In this blog for World Patient Safety Day, Patient Safety Learning sets out the scale of avoidable harm in health and care and highlights the need for a transformation in our approach to patient safety.

It also reflects on the theme of this year’s event, ‘Improving diagnosis for patient safety’, and our World Patient Safety Day blogs shared on the hub, drawing out some key areas, including:

• rapid and timely diagnosis
• improving investigations into diagnostic error
• the importance of listening to patients
• accessibility and diagnostic services
• diagnostics and digital health.

Content

Today is the sixth annual World Patient Safety Day. Organised by the World Health Organization (WHO), this event was first established in 2019 at the 72nd World Health Assembly.[1] World Patient Safety Day calls for global solidarity and concerted action by all countries and international partners to improve patient safety.[2]

Patient safety and avoidable harm

Patient safety, simply put, is concerned with avoiding unintended harm to people during their care and treatment. WHO defines it as:

“Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur.”[3]

Modern healthcare is increasingly complex and there are many ways that avoidable harm can occur during care and treatment. WHO estimates that:

• 1 in every 10 patients is harmed while receiving hospital care.
• In low-to-middle income countries, as many as 4 in 100 people die from unsafe care.
• Above 50% of harm (1 in every 20 patients) is preventable.[4]

In the UK, prior to the Covid-19 pandemic, NHS England stated that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed.[5] However, in practice this figure is now likely to be a significant underestimate, given the ongoing enormous strain faced by the healthcare system.[6]

Every avoidable death and disability is an unnecessary tragedy for patients, families and healthcare professionals. In addition, patient harm comes with a huge financial footprint. The Organisation for Economic Co-operation and Development (OECD) estimates that in high-income countries the direct cost of treating patients who have been harmed during their care approaches 13% of health spending.[7] Excluding safety lapses that may not be preventable, this figure is 8.7% of health expenditure.[8] In the UK, the latest annual report from NHS Resolution estimates that the cost of harm covered by the Clinical Negligence Scheme for Trusts alone was £4,778 million in 2023/24.[9]

Transforming our approach to patient safety

The need to make significant improvements to patient safety in health and care is widely recognised. However, despite this knowledge, and the hard work of many people involved in the sector, avoidable harm continues to persist at an unacceptable rate. This avoidable harm is driven by the failure to address the complex systemic causes that underpin this.

In our report, A Blueprint for Action, we set out the need for a transformation in the health and care system’s approach to patient safety.[10] This outlines how, too often, patient safety is typically seen as a strategic priority, which in practice will be weighed (and inevitably traded-off) against other priorities. To transform our approach to this, we believe it is important that patient safety is not just seen as another priority, but as a core purpose of health and care. Underpinned by systemic analysis and evidence, the report identifies six foundations of safe care of patients and practice actions to address them:

• Shared learning
• Professionalising patient safety
• Leadership
• Patient engagement
• Data and insight
• Culture

Improving diagnosis for patient safety

One of the key sources of patient safety incidents that result in avoidable harm is diagnostic error. Errors can happen at every stage of the diagnostic process in all healthcare settings. WHO estimates that diagnostic errors account for nearly 16% of preventable harm across healthcare systems.[11] Most adults are likely to face at least one diagnostic error in their lifetime.

Diagnostic errors can be divided into three categories:

1. Delayed diagnosis—where harm is caused because of a health condition not being identified at an earlier stage. This may happen because of failure to use the correct tests, outdated forms of assessment or failure to act on results of monitoring or testing.
2. Incorrect diagnosis—where the wrong diagnosis is made and the true cause is discovered later. This can lead to patients receiving the wrong treatments, which may even be harmful. They also may not receive the appropriate treatment for their condition, with this delay potentially leading to poor outcomes and increased risk in mortality.
3. Missed diagnosis—where a patient’s illness or health condition is not identified, which can result in their condition worsening and avoidable harm because they are not receiving any treatment.

WHO has identified ‘Improving diagnosis for patient safety’ as the theme of this year’s World Patient Safety Day, stating that:

“Diagnostic safety can be significantly improved by addressing the systems-based issues and cognitive factors that can lead to diagnostic errors. Systemic factors are organizational vulnerabilities that predispose to diagnostic errors, including communication failures between health workers or health workers and patients, heavy workloads, and ineffective teamwork. Cognitive factors involve clinician training and experience as well as predisposition to biases, fatigue and stress.”[12]

At Patient Safety Learning, we strongly agree with this message and the importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.

Exploring diagnostic safety

In support of this year’s theme of improving diagnosis for patient safety, we have published a new series of blogs on the hub, our global platform to share learning for patient safety (sign up here for free). These contributions have come from many different perspectives, including patients, researchers, healthcare professionals and representative charities.

Rapid and timely diagnosis

Early diagnosis is key to ensuring effective treatment and improved patient outcomes across a range of different health conditions. Cancer care is a prominent example of this. Diagnosing a cancer early significantly increases the chance of successful treatment.

Writing from a GP’s perspective, Dr Amelia Randle sets out a number of ways healthcare professionals can develop their daily practice to improve early diagnosis of cancer.[13] In a separate article, Alfie Bailey-Bearfield from Pancreatic Cancer UK explains the challenges associated with diagnosing pancreatic cancer.[14] He sets out why fast and accurate diagnosis is so important, and why increased funding is vital to improving outcomes for patients.

Aortic dissection is another condition where timely and accurate diagnosis is crucial due to the potential for catastrophic outcomes if left undiagnosed. The Aortic Dissection Charitable Trust shared Martin’s experience of an aortic dissection when out on a morning run. His recovery story illustrates the positive impact of prompt testing and treatment.[15]

Improving investigations into diagnostic error

Too often patient safety investigations do not result in the learning and improvement needed to prevent future incidents of avoidable harm. This is a problem that applies across a range of patient safety issues, including diagnostic safety.

Dr Dan Cohen, a former US Department of Defense physician executive and a member of our Board of Trustees, looks at the challenges around diagnostic error and delay, and how they are compounded by human factors, cognitive bias and the Covid-19 pandemic.[16] Ending with a case study, he illustrates how high-quality investigations, that delve deeply into human factors and focus less on blame, are key to reducing harm. In his concluding comments, he notes:

“Investigations focused on diagnostic failures, and delays in diagnosis and appropriate care, provide opportunities for real learning and improvement. Shoddy investigations that assign blame and do not delve deeply to understand human behaviour should be considered illustrations of poor understanding. They are best dismissed as ineffectual relics of the past never to be revived again.”[16]

 Anna Paisley, also highlights the link between cognitive bias and diagnostic error in her blog on improving diagnostic safety in surgery.

“A robust diagnostic process relies not only on the knowledge and training of surgeons but also on cognitive factors, such as bias and limitations in clinical reasoning or failures of perception, which have been linked to up to 80% of diagnostic errors in surgery.”[17] [18]

Importance of listening to patients

A theme that emerges repeatedly in inquiries and reports into serious patient safety incidents is a failure to listen to patients, family members and caregivers when they raise concerns. Too often there is also a failure to involve them appropriately in investigations after harm has occurred.

In an anonymous blog, a patient explains how her experiences of pain were dismissed after the birth of her first baby.[19] Although her own research indicated she had rheumatoid arthritis, the patient explains how she had to battle misinformed and unhelpful doctors to get a referral to a specialist. This led to delays in her diagnosis, leaving her questioning whether life would be different had she been believed sooner. Describing this experience, she says:

“My symptoms and interactions with healthcare over that year had a deep impact on me. It affected my physical health in obvious ways, but it also had a negative impact on my mental health. The stress of knowing something is very wrong but feeling like no one who can help believes you is enormous.”[19]

We have also shared an article about the relationship between communication and diagnostic accuracy.[20] Dr Mary Dahm and Dr Carmel Crock draw on research findings to highlight how critical it is to spend time listening to the patient, and for doctors to communicate uncertainties well. 

Accessibility and diagnostic services

Everyone has the right to be able to access diagnostic tests in a way that works for them. A failure to meet people’s requirements for access can have serious consequences, delaying or preventing diagnostic tests or associated treatment.

In a new blog, Pavi Brar, Senior Policy Advisor at National Voices, explains how many people are facing accessibility barriers to diagnostic services despite the policy and legislation in place. Drawing on examples and insights from National Voices members, Pavi highlights how equipment needs are too often not being met for patients.

“Sex With a Difference (SWAD) is a training organisation specialising in the area of disability and sex. They told us some people have had prostate cancer tests whilst kneeling on the floor of a GP surgery, as they were unable to get onto the couch. Another person was three years late in having a smear test as an accessible couch was not available to them. Patients with accessibility needs should not be forced to choose between prompt or dignified care.”[21]

Diagnostics and digital health

The use of digital health technologies are a familiar part of everyday health and care, with an increasing interest in how artificial intelligence (AI) can be used to make improvements.

The advance of AI has seen the emergence of digital diagnostic tools, with some claiming a more accurate diagnosis than a human.[22] Clive Flashman, Patient Safety Learning's Chief Digital Officer, writes about some of these new digital diagnostic tools that are becoming increasingly available not only to clinicians but also for patients. He highlights some of the risks that they bring and considerations that need to be thought through.

In his concluding comments, Clive notes:

“It is inevitable that we will move to see more digital health diagnostics used by healthcare professionals and patients. However, we should not forget that this will not be appropriate for some people and offer other options for them to gain a formal diagnosis. People using digital diagnostic tools should be able to call on support where they need it and the guardrails that we have in place should be continuously reviewed so that they deal with new and innovative technologies before they cause significant harm to users.”[23]

Ben Jeeves, Associate Chief Clinical Information Officer and Clinical Safety Officer, also talks about how exponential growth in technology will directly impact diagnostic safety in his blog about digital clinical safety in diagnosis. He highlights too that with this technology new risks are introduced, which need to be accounted for and mitigated against.[24]

Share your experiences on the hub

We would welcome your views on improving diagnosis for patient safety.

Are you a patient who has been affected by a delayed, incorrect or missed diagnosis? Or perhaps a healthcare professional with an example of an improvement project that aims to reduce diagnostic error and improve outcomes?

You can share your experience in our community forum (sign up here for free first), submit a blog, or email us at [email protected].

You can also find a number of existing resources, tools and stories relating to diagnosis and patient safety on the hub here.

References

1. World Health Assembly. WHA 72.7 – Global action on patient safety, 28 May 2019.
2. WHO. World Patient Safety Day, Last accessed 10 September 2024.
3. WHO. Patient safety – About us, Last accessed 10 September 2024.
4. WHO. Patient Safety, Last updated 11 September 2023.
5. NHS England. The NHS Patient Safety Strategy Safer Culture, safer systems, safer patients, July 2019.
6. Lord Darzi. Independent investigation of the NHS in England, 12 September 2024.
7. OECD and Saudi Patient Safety Center. The Economics of Patient Safety. From analysis to action, 21 October 2020.
8. Helen Hughes. Improving patient safety: a financial imperative. Healthcare Financial Management Association, 17 May 2023.
9. NHS Resolution. NHS Resolution annual report and accounts 2023 to 2024, 23 July 2024.
10. Patient Safety Learning. The Patient-Safety Future: A Blueprint for Action, 2019.
11. WHO. Announcing World Patient Safety Day 2024, Last accessed 16 April 2024.
12. WHO. World Patient Safety Day, 17 September 2024: “Improving diagnosis for patient safety”, Last accessed 14 September 2024.
13. Randle A. Catching cancer early: what more can we do as GPs? Patient Safety Learning, 19 September 2024.
14. Bailey-Bearfield A. Pancreatic Cancer: striving for early, fast and accurate diagnosis. Patient Safety Learning, 12 September 2024.
15. The Aortic Dissection Charitable Trust. How early diagnosis saves lives: case study on aortic dissection. Patient Safety Learning, 16 September 2024.
16. Cohen D. Diagnostic errors and delays: why quality investigations are key. Patient Safety Learning, 9 September 2024.
17. Paisley A. Improving safety in surgery: A blog by Anna Paisley. Patient Safety Learning, 17 September 2024.
18. Kwan JL, et al, Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada. Canadian Journal of Surgery, 6 February 2024.
19. Anonymous. Rheumatoid arthritis: would my life be different if I had been diagnosed sooner? Patient Safety Learning, 10 September 2024.
20. Dahm M, Crock C. “Listening to a patient’s history for longer can help doctors make the right diagnosis”. Patient Safety Learning, 16 September 2024.
21. Brar P. Diagnostic safety: accessibility and adaptions–a (un)reasonable adjustment. Patient Safety Learning, 16 September 2024.
22. IHI Lucian Leape Institute. Patient Safety and Artificial Intelligence: Opportunities and Challenges for Care Delivery, May 2024.
23. Flashman C. Digital diagnosis–what the doctor ordered? Patient Safety Learning, 11 September 2024.
24. Jeeves B. Applying a robust approach to digital clinical safety in diagnosis. Patient Safety Learning, 17 September 2024.