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Content includes: Patient Safety: We’ve Come a Long Way National Patient Safety Consortium: Learning from Large-Scale CollaborationPatient Engagement in a Large-Scale Change Initiative: “As Safe as Possible, as Soon as Possible” Commentary: Three Ideas About “Post-Vention” Patient Safety Never Events: Cross-Canada Checkup Empowering Patients: 5 Questions to Ask About Your Medications Accelerating Post-Surgical Best Practices Using Enhanced Recovery After Surgery Patient Safety Culture Bundle for CEOs and Senior Leaders Commentary: We Must Look at Multiple Perspectives Homecare Safety Virtual Quality Improvement Collaboratives Commentary: Patient Safety in the Home Measuring and Monitoring Healthcare-Associated Infections: A Canadian Collaboration to Better Understand the Magnitude of the Problem Patient Safety: Patient Involvement Matters.

After working last week and caring for patients who were pending COVID-19 swab results, four days later I woke feeling unwell. A slight cough, tired, pale, feeling freezing cold but no temperature and generally feeling rubbish. This carried on for a few days, I then ended up with common cold-like symptoms and a residual cough. Normally, I probably wouldn’t call in sick, I would have just carried on. Following current guidance, I called in sick and was advised to take the next 7 days off. At this point testing was unavailable for NHS staff. I was sat at home not knowing if I had the virus or not while my colleagues were having to pick up the slack. If I am completely honest, I was glad I didn’t have to go back. I was anxious that we didn’t have the right personal protective equipment (PPE), systems for donning and doffing were not in place, we didn’t know what to expect over the coming days, training for redeployed nurses and doctors was not happening. I just didn’t want to go back anyway. I felt a coward. Over the coming days while I was at home, my husband then became ill, then my youngest son, then the eldest. All with mild symptoms, but still no idea if we had it or not. While I was off, I was contacted by the ‘staff welfare team’. It was just a quick phone call to see how I was, but it made all the difference. I felt like I wasn’t just a ‘worker’ off sick, I was someone that they cared about and were obviously keen to make sure I was coming back! This has never happened before. Reluctantly, I return to work, but it was like I had stepped into a different Trust. Wards with infected patients were labelled as RED wards; huge signs were outside the wards with designated places to don and doff PPE. There were clear guidance on which PPE to wear displayed in poster format. There were green footsteps and red footsteps on the floor enabling you to know which area you were in. PPE safety officers had been deployed to reassure and ensure all departments have enough stock. It felt safer. Leadership at all levels is being tested at this time. Where I work in Brighton, we are invested in ‘Patient First’. This is headed up by our Kaizen Team. All staff are trained in differing levels of quality improvement (QI). All wards and departments have improvement huddles, where they can raise a mini project and see it through. We all speak the same QI language. I dread to think what would happen if we didn’t have this in place during this awful time. By having this process, it has empowered ALL staff to speak up and give permission for frontline staff to improve processes where they work. Our executive leadership team have done an amazing job in such a small amount of time. They have increased ITU capacity, they have reshaped rotas, redeployed staff, re employed staff, transformed patient pathways (red and green pathways), pooled staff, set up systems for donations… There has been so much achieved in a short amount of time; the top-level organisation has been incredible. All this in seven days. They have been phenomenal at strategy, planning and overall management and leadership of what I call ‘the big stuff’. What they are not so good at is the ‘small stuff’. We, frontline workers are brilliant at this. The practicalities of work – where can I don and doff, where the bins should be, how do I know this bed has been cleaned? What do we do when someone dies? Can relatives visit? How do we know who is who in PPE? How can we make sure we don’t contaminate clean areas? How do we take blood now? We know what needs to be improved, we know what is missing. It’s the small details that worries staff, it’s the small details that can save lives. As I was walking seeing patients from different wards, I heard staff saying – this isn’t right – we could improve that. They can raise a ticket on the huddle board and they could initiate the change. If the change could be replicated else where in the Trust, the Matron or ward manager can then raise it at the Bronze meeting, the bronze would then raise it to Silver and then implemented. I often hear that we use a top down, bottom up approach but never really thought it works, as there is so much red tape involved in healthcare. Quite often frontline ideas never reach the top level and they fall flat. This time it’s very different. To test the system, you need to stress the system. This system of QI and communication is working. We are all learning together. None of us have dealt with a pandemic before. Frontline staff have been given the permission to improve the way real work is done, quickly and safely, while the top-level management are concentrating on strategy, planning, implementation and co-ordination of services. We are listening to each other, we are rapidly changing and adapting, the whole Trust is in a constant state of PDSA cycles. It feels dynamic, proactive and controlled. If this pandemic happened 10 years ago in our trust, I am convinced that we would not be in the position we are now. We have enough intensive care beds, we have the capacity to expand further, we are ready.

This article is about accepting that our working lives are difficult, that this is a big part of the attraction of our work and that it is wise to look at ways in which both team and personal resilience can be improved.

The paper acknowledges the success, failure and efficiency of all safety efforts is fundamental to the experience of patients and families. In addition, the safety systems in place in an organisation directly shape and define the clinician’s experience. Generated from these concepts, key recommendations in integrating safety and experience are explored: • acknowledge safety as a primary driver for overall experience of both patients and clinicians • approach safety and patient experience through a unified lens • make financial choices that reflect a commitment to the experience of safety • make a conscious, accountable and strategic effort to build a culture of caring • optimise technology to care for the caretakers • engage patient and family voice to lead change and drive future solutions.

On January 2020, Patient Safety will be on the G20 agenda (amongst other five health key priorities). One would ask: What is Patient Safety doing on an economic forum like the G20? Another cynic might even add: What is Healthcare doing on the G20? The G20 was established in the late 1990s with the objective of its members working together to achieve economic and financial stability. It is comprised of 19 countries and the European Union (EU). The G20 collectively represent more than 85 % of the world’s Gross Domestic Product (GDP), and more than two- thirds of the world’s population. Healthcare was only introduced in 2017 during the German presidency. Why put patient safety on the G20 agenda? Patient harm is estimated to be the 14th leading cause of the global disease burden. This is comparable to medical conditions such as tuberculosis and malaria. In both U.S. and Canada, Patient Safety Adverse Events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the U.S. alone: 440 thousand patients die annually from healthcare associated infections (HAIS). In Canada: there are more than 28 thousand deaths a year due to Patient Safety Adverse Events. In Low – Middle Income Countries (LMIC), every year 134 million adverse events take place resulting in 2.6 million deaths annually. Having said all that, up to 70 % of harm is . (OECD, 2017) In addition to lives lost and harm inflicted, unsafe medical practice results in money loss. Nearly, 15 % of the health expenditure across Organization of Economic Cooperative Development (OECD) countries is attributed to patient safety failures each year (OECD 2017) But if we add the indirect and opportunity cost Economic & Social), the cost of harm could amount to trillions of dollars globally (OECD 2017). According to a report by Frost & Sullivan in 2018, Patient Safety Adverse Events cost the US alone 146.1 billion dollars annually. When you compare the cost of prevention to the cost of harm, the return on investment (ROI) becomes a “no brainer”. In a study that looked at patient safety ROI for Pressure Injuries, the cost of prevention was € 291.33 million compared to the cost of harm of € 2.59 billion (almost 1,000 times higher). (Demmarre et al 2015) Over the past 20 years, numerous efforts were made to improve patient safety in individual G20 countries as well as globally under the World Health Organization leadership. Despite all those efforts, the level of harm to patients persists and 20-40% of health resources are being wasted (WHO). Many healthcare structural causes are responsible for the ongoing harm: Healthcare Workforce Factors: In addition to the quality and quantity, the wellbeing and safety of health workforce are foundational to patient safety. A substantial body of research now points to link nurse staffing with patient outcomes. A business case by Needleman (2006) demonstrated cost saving from reduced complications and shorter length of stay associated with higher nurse staffing levels. This relationship is articulated clearly in the Jeddah Declaration on Patient Safety in 2019. Dall (2009) estimated the impact of increased nurse staffing on medical cost, lives saved and national productivity. Their research suggests that adding 133,000 nurses to U.S. hospitals would save 5900 lives per year, increase productivity by $1.3 billion, or about $9900 per year per additional nurse. Decrease in length of stay resulting from this additional nurse staffing would translate into medical savings of $6.1 billion and increased in productivity attributed to decreased length of stay was estimated at $231 million per year. Addressing and ensuring guidelines that are consistent with research findings for nursing staffing in acute settings is a viable key solution to prevent medical errors, improve patient safety and decrease cost of healthcare delivery. Healthcare Education Causes: Even though healthcare is provided by multi-disciplinary teams, healthcare education (undergraduate – postgraduate) continues to be conducted in separate settings. This siloed approach results in many of the communication failures / safety failures that are experienced on a regular basis. According to Joint Commission communication failures were the leading root cause of the sentinel events reported to the Joint Commission from 1995 to 2004. Healthcare education requires a serious reevaluation of its current curricula and practices. Furthermore, the lack of patient safety components to the medical and allied health sciences curriculum does a disservice to have safe medical practices imbedded within the day-to-day implementation of the healthcare workforce. Patient – Provider Information Asymmetry: The information and communication gap between the healthcare providers and their patients has caused ongoing harm. With the information abundance, patients turned to the internet as a source of guidance, regardless of its accuracy, which is minimally provided by Healthcare teams. Healthcare providers need to be the trusted guidance for information and the empowering force for patients to make informed decisions. Unempowered patients may result in lack of transparence and noncompliance to the care plans that contribute patient harm. Major movement for patient empowerment and community engagement is warranted. In addition, engaging patients can reduce the burden of harm by about 15%, saving billions of dollars each year. (WHO) Poor Safety Culture: The Hospital Survey on patient safety culture has been implemented in many countries to gain insight on the employees’ perception of the hospital patient safety culture. It has been consistently found that employees perceive hospital cultures lack transparency and results in punitive consequences when adverse events are reported. ‘Shame and Blame’ culture is one of the major barriers to improving safety. It is imperative that healthcare systems adopt strategies enabling Just Culture. Lack of consideration of Human Factors: In the healthcare sector, and since the Institute of Medicine (IOM) report “To Err is Human”, have come a long way in improving our services with elimination of potential harm in mind. However, healthcare can learn much more from other industries that have improved safety through use of HFE in redesigning work process and flow to ensure they are error-proof. HFE is an important discipline that can embed resilience to healthcare systems and could, potentially, transform patient safety. Lack of sufficient sharing and learning: The different sectors within the healthcare industry have created silos based on profession, departments, type of organization and many more subcultures and entities within a facility and at the national levels. This results in fragmented systems working in isolation, creating piece meal solutions and multi-levels of communication gaps, let alone the opportunity to share and learn in a manner that prevents harm from being repeated. Learning (from within healthcare), through Reporting & Learning Systems, and (from other industries), e.g. aviation, nuclear, oil & gas, is essential to healthcare safety innovation and transformation. Furthermore, population ageing has significant implications for patient safety as older adults are at higher risk for medical errors and the rate of adverse events due to increases in frailty, comorbidities, and incidences of chronic conditions, falls, and dementia makes providing health care more complex and increases costs. Individuals 65 years and older are at a two-fold risk for developing adverse events when compared with individuals between the ages of 16 and 44 years. (Brennan TA, Leape LL, Laird N, et al.) Nations across the G20 will face this challenge, which necessities innovate safety interventions and new approaches in health care to design a safer health care system. When it comes to patient safety, doing more of the same will result in: More lives will be lost More preventable harm will take place like Healthcare Associated Infections, medication errors, Anti-microbial Resistance (AMR) …etc. More money will be wasted (not to mention indirect cost and opportunity cost). When a patient is harmed, the COUNTRY LOSES TWICE: The individual will be lost as a revenue generating source for society+ the individual will become a burden on the healthcare system because he or she will require more treatment. Unless we do something different about patient safety, we would risk the sustainability of healthcare systems and the overall economies. Our G20 proposal for patient safety Establishing a G20 Patient Safety Network (Group) that will combine two types of expertise: Safety experts from healthcare and other leading industries (like Aviation, Nuclear, Oil & Gas, other) Economy and Financial Experts This will function as a platform to prioritize and come up with innovative patient safety solutions to solve Global Challenges while highlighting the return on investment (ROI) aspects. This multidisciplinary group of experts can work with each state that adopts the addressed Global Challenge to ensure correct implementation of proposed solution. Benefit Investment in Patient Safety – – > sustainability of healthcare systems – – > and overall economies. In conclusion, patient safety is a global priority that goes beyond healthcare. It is a challenge that requires the collective wisdom of the G20 and the overall global community. It is not just an issue for health ministers, but it is an important issue that requires the attention of finance ministers and heads of states. The economic cost of failing patient safety could be risking the sustainability of healthcare systems and the overall global economies. WE NEED TO ACT NOW!

Key take-away messages The healthcare organisation you work in is a system of interacting human elements, roles, responsibilities and relationships. Quality and patient safety are performed by your human-designed organisational structures, processes, leadership styles, people's professional and cultural backgrounds, and organizational policies and practices. The level of interconnection of all these aspects will impact the distribution of perception, cognition, emotion and consciousness with the organisation you work for. What goes on between people defines what your health system is and what it can become.

I used to work for the World Health Organization (WHO) helping to establish its patient safety programme over 20 years ago. Last week I was invited back to attend a three day WHO meeting on behalf of Patient Safety Learning to contribute to the development of its Global Patient Safety Action Plan for 2020-2030. Heading into this event, I had several key questions at the front of my mind: What have we learned about patient safety in the last twenty years? Why does harm remain so persistent? What impact has the global commitment to patient safety had in reducing harm? What approaches to patient safety are having the most impact? How can we be more effective share learning for safer care? A truly global problem This event took place within the context of the resolution of World Health Assembly (the decision-making body of WHO which is attended by delegations from all member states) in May 2019. This WHA resolution agreed to address global patient safety in a concerted manner. The meeting last week was to take this forward by developing a Global Patient Safety Action Plan between member states and the WHO to reduce unsafe care. In the introductory speeches the huge scale of the problem was set out: WHO considers that unsafe care is one of the 10 leading causes of death and disability worldwide. There are 134 million adverse events in hospitals in low and middle income countries, resulting in 2.6 million deaths annually. 1 in every 10 patients are harmed while receiving hospital care in high income countries. In addition to the shocking human cost, it was noted that patient safety incidents also serve to erode trust in healthcare and come with a major economic penalty – with it being estimated that nearly 15% of all health expenditure is attributed to patient safety failures annually, running into a trillions of dollars each year. Maintaining momentum Sir Liam Donaldson (WHO Envoy for Patient Safety) outlined in his introductory comments at this event the importance of maintaining momentum from the WHA resolution to tackle the issue patient safety in a global movement for change. He talked about his decision to become a doctor as a decision of the heart. As his career developed into leadership roles in the UK and at WHO, his head often ruled his heart but now he thinks it’s the heart that should drive us and our ambition to reduce harm. He also highlighted six current power blocks are not doing enough to improve safety and that need to be engaged and motivated to achieve change: Designing of health systems - to date there is not much evidence that systems are being designed for safety Health leaders - they are currently not using their power to lead for reduced harm Educational institutions - we need quicker developments to train staff Research community - there are questions as to whether patient safety research has led to sustainable reduction in risk Data and information - he questioned how effectively this has been employed to improve patient safety Industry - he noted the need for more action on this front, citing the example of the pharmaceutical industry on medication packaging and labeling and the need for more action by the medical devices industry. Implementing the Global Patient Safety Action Plan Dr Neelam Dhingra-Kumar (Coordinator for Patient Safety and Risk Management at the WHO) gave a presentation on the initial plans to implement a Global Patient Safety Action Plan. In this she set out the intention to set guiding principles and strategic objectives at a global level which could then be developed into actions at a country level, with the results subsequently informing SMART (Specific, Measurable, Achievable, Realistic, Time-Orientated) global patient safety goals. You can view her full presentation on the hub. A shared vision for patient safety The morning of the first day had contribution from global leaders on their vision for patient safety, from a patient and family perspective, from a patient safety experts, from a Ministry of Health representative and a list of proposed statements for vision, goals and guiding principles. At the very start of this session was… Patient engagement for patient safety Sir Liam Donaldson noted the important role that patients play in highlighting instances of unsafe care and noted that often ‘patients are not empowered to prevent their own harm’. Sue Sheridan (Co-founder of Parents of Infants and Children with Kernicterus (PICK) and the former lead of the WHO Patients for Patient Safety programme) developed on this theme, emphasising the importance of viewing patient safety through the lens of patients and families. She noted that they had a key role to play in making change happen and co-producing safer healthcare systems. Sue identified some common threads required for co-production of safer healthcare: Developing a core of diverse skilled family members who are willing to be partners in this work. Growing and incentivising creative and passionate healthcare leaders in patient engagement in quality improvement, research and policy. The importance of embedding patients in governance, strategic priorities and with funded programmes. The need for capacity building skills for patients (to inform and influence) and for professionals (to effectively partner with patients). Hard-wiring budgets so that there are the funds to enable this work. Systematically review outcomes. Develop a repository of co-production best practice. Sue highlighted that for patients and civil society to have a powerful voice, they must be supported with the appropriate tools and training and that institutions must embrace social movement with courageous leaders to co-produce safe care with patients. Key themes of patient safety implementation The remainder of the day was devoted to presentations on the key themes of implementation. I have listed these below and have selected a few of the topical areas to talk about in more detail that in my view, represented a new or strengthened perspective. Theme 1: Safety in patient care, clinical processes and use of medical products and devices. Theme 2: Patient safety policy and priorities. For the first time, patient safety has been included on the G20 agenda. Dr Abdulelah Alhawsawi (Director General at the Saudi Patient Safety Center) outlined the important role that the G20 can play in provide leadership on a global level for patient safety. In doing this he outlined the core features of the G20 Global Patient Safety Framework that is currently being developed: Patient Safety Culture. Resilience - recognising that all clinicians have harmed, and that healthcare is complex and the need for Human factors to be employed to address systems problems. Advocacy - everyone knows about global climate change, but people have not heard about the global patient safety challenge. This must change and we must advocate for this change. Information asymmetry – the importance of effective patient and family empowerment and real co-production with patients, making sure that they have the right tools to do this. Collective wisdom and learning – the importance of using data and effective means of measurement. Theme 3: Leadership and patient safety culture. Theme 4: Patient safety education and training. Theme 5: Human factors capability and capacity Dr Huda Amer Al-Katheeri (Director of Strategic Planning and Performance Development in Qatar) and Dr Kathleen Mosier (President of the International Ergonomics Association) gave a presentation on the role of Human factors/ergonomics in healthcare. In this they illustrated how poor Human factors is a healthcare in a consistent feature among patient safety failures, with systems often poorly designed and not tailored to the context/people involved. They outlined how Human factors can be integrated make healthcare systems more resilient for patient safety and the need to building these skills among workforce and enable greater participation. You can view their full presentation on the hub. Theme 6: Measurement, reporting, learning and surveillance. Theme 7: Patient safety research and innovation. Theme 8: Global Patient Safety Challenges. Theme 9: Patient engagement and empowerment. Theme 10: Patient safety in an era of universal health coverage. Theme 11: Developing networks and partnerships. Theme 12: WASH – Water, sanitation and hygiene, infection prevention and control. Coming up in part 2… In part 2 of the blog next week, I’ll talk about the discussions that took place on the second and third days of the event, highlighting the key issues that came up in the plenary session and reflecting on how this work should be taken forward.