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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!

Implications While this study shows that those referring patients to ICU could benefit from greater support, the decision support tool trialled in this study would need some adaptation to fit the time-pressured realities of the users. The process did seem to help clinicians articulate and communicate their reasoning for admission. Perhaps, as the authors say, if the tool were to be integrated into existing systems the perceived additional workload may be diminished. Another not insignificant finding is that although clinicians stated they valued patient’s wishes, in some cases there was a lack of patient and family involvement.

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.

In my current role I oversee the therapy programme for the Eating Disorders Unit (EDU) and see in-patients, day-patients and out-patients for individual and group therapy. I work with both adults and children with eating disorders, depression and anxiety, and use evidence-based therapies including cognitive behavioural therapy (CBT). A case study Lucy* is a 25-year-old interior designer who is seeking treatment for anorexia. She was an inpatient on our EDU. Throughout the whole admission there is a strong focus on patient safety. One of Lucy’s goals was to gain weight to a safer weight, but the increases were very gradual to avoid refeeding syndrome. At the beginning of her stay and all throughout we carried out regular risk assessments to check her risk to herself and also to others. Lucy had her bloods monitored throughout and was regularly observed for physical symptoms. In terms of the therapy, our focus was looking at the role that anorexia played in Lucy’s life. To do this we did a collaborative formulation which was continually evolving. This helped Lucy to make more sense of her illness and understand what it meant to her. Lucy was able to articulate that her anorexia made her feel ‘special’ and also was a way of managing difficult feelings such as feeling upset and angry by her parents’ divorce. Lucy was also able to identify that feelings were not spoken about in her family, so she did not have the ability to identify and name feelings. Lucy did very well in therapy managing both the physical and mental challenge of gaining weight. Over time, Lucy found different ways of managing her feelings such as talking to others, distracting herself and writing a journal. An essential part of our work is relapse management and ensuring that patients learn from their ‘blips’ instead of viewing them as failings. Key learning points I am flexible in tailoring treatment to patients’ needs and it is important to build a warm and trusting therapeutic relationship with patients. As part of my role I work closely with the multidisciplinary team and regularly present to other healthcare professionals about the complexities of treating people with eating disorders and related conditions and to ensure the patient's safety is always met. Here are some of my suggestions when treating children and adults with eating disorders: It is important to remember that whilst sometimes people with eating disorders can look very emaciated and frail, at other times they can be a normal weight and look well. It is therefore vital that health professionals do not solely use weight to diagnose an eating disorder. People with eating disorders often have a great deal of shame and so may not readily disclose their symptoms and instead may present with physical problems such as bowel problems. It is helpful if health professionals ask question such as "do you ever restrict your food" or "do you ever experience guilt after eating". Treatment for an eating disorder involves monitoring both the physical and psychological health of the patient. In order to ensure the physical safety of patients, tasks include monitoring electrolyte levels, assessing for risk and assessing patients nutritional and fluid levels. Eating disorders are complex mental illnesses in which patients use food in different ways to cope with difficult feelings. Health professionals should aim to build a positive therapeutic relationship with patients and should have a non-judgmental and accepting attitude towards them. *Name and details of patient have been changed to preserve confidentiality.

The WHO Flagship Initiative “A Decade of Patient Safety 2020-2030” will: Respond to global movement and latest developments in the area of patient safety. Give due prominence to the concept “First do not harm” and patient safety area of work. Call for political commitment and immediate action at country level. Leverage resources (internal and external/financial and human). Ensure institutional mechanisms within the organisation for coordinated work across departments/divisions, especially with disease-specific programmes.

Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time!

Working with colleagues across the health service community, they are focusing on these key areas: Safer Care through NEWS2 (National Early Warning Score) Emergency Department Safety Checklist Emergency Laparotomy Collaborative Structured Mortality Reviews.