Edward Kelley

Establishing a global learning community for incident-reporting systems

Background Incident-reporting systems (IRS) collect snapshots of hazards, mistakes and system failures occurring in healthcare. These data repositories are a cornerstone of patient safety improvement. Compared with systems in other high-risk industries, healthcare IRS are fragmented and isolated, and have not established best practices for implementation and utilisation. Discussion Patient safety experts from eight countries convened in 2008 to establish a global community to advance the science of learning from mistakes. This convenience sample of experts all had experience managing large incident-reporting systems. This article offers guidance through a presentation of expert discussions about methods to identify, analyse and prioritise incidents, mitigate hazards and evaluate risk reduction.

Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations

Health care-associated infections (HAI) are a major public health problem with a significant impact on morbidity, mortality and quality of life. They represent also an important economic burden to health systems worldwide. However, a large proportion of HAI are preventable through effective infection prevention and control (IPC) measures. Improvements in IPC at the national and facility level are critical for the successful containment of antimicrobial resistance and the prevention of HAI, including outbreaks of highly transmissible diseases through high quality care within the context of universal health coverage. Given the limited availability of IPC evidence-based guidance and standards, the World Health Organization (WHO) decided to prioritize the development of global recommendations on the core components of effective IPC programmes both at the national and acute health care facility level, based on systematic literature reviews and expert consensus. The aim of the guideline development process was to identify the evidence and evaluate its quality, consider patient values and preferences, resource implications, and the feasibility and acceptability of the recommendations. As a result, 11 recommendations and three good practice statements are presented here, including a summary of the supporting evidence, and form the substance of a new WHO IPC guideline.

WHO efforts to promote reporting of adverse events and global learning

Despite the importance of reporting systems to learn about the casual chain and consequences of patient safety incidents, this is an area that requires of further conceptual and technical developments to conduce reporting to effective learning. The World Health Organization, through its Patient Safety Programme, adopted as a priority the objective to facilitate and stimulate global learning through enhanced reporting of patient safety incidents. Landmark developments were the WHO Draft Guidelines for Adverse Event Reporting and Learning Systems, and the Conceptual Framework for the International Classification for Patient Safety, as well as the Global Community of Practice for Reporting and Learning Systems. WHO is currently working with a range of scientists, medical informatics specialists and healthcare officials from various countries around the world, to arrive at a Minimal Information Model that could serve as a basis to structure the core of reporting systems in a comparable manner across the world. Undoubtedly, there is much need for additional scientific developments in this challenging and innovative area. For effective reporting systems and enhanced global learning, other key contextual factors are essential for reporting to serve to the needs of clinicians, patients and the healthcare system at large. Moreover, the new data challenges and needs of organizations must be assessed as the era of big data comes to heath care. These considerations delineate a broad agenda for action, which offer an ambitious challenge for WHO and their partners interested in strengthening learning for improving through reporting and communicating about patient safety incidents. Significance for public health Understanding the causes and consequences of incidents is cornerstone for patient safety improvement. Likewise, setting up systems to facilitate such understanding and communicate the learning across all healthcare actors is crucial. Over the past decade, the World Health Organization has convened an area of work, with the support of a growing number of collaborating agencies, institutions and experts worldwide to facilitate the identification of global directions aiming to facilitate the development and management of patient safety incident reporting systems as well as the extraction and communication of useful learning. Exchange and sharing of best practices and experiences has been at the essence of this work. This paper describes such efforts and also reflects on other areas of work which are essential to enhance patient safety by learning from the failures of the health care.

Charting the way forward to better quality health care: how do we get there and what are the next steps? Recommendations from the Salzburg Global Seminar on making health care better in low- and middle-income economies

OBJECTIVE In April 2012, the Salzburg Global Seminar (SGS) brought together 58 health leaders from 33 countries to review experiences in improving the quality and safety of health-care services in low- and middle-income countries, synthesize lessons learned from those experiences, discuss challenges and opportunities and recommend next steps to stimulate improvement in such countries. This work summarizes the seminars key results, expressed as five shared challenges and five lessons learned. DESIGN The seminar featured a series of interactive sessions with an all-teach, all-learn approach. Session topics were: introduction to the seminar, journey to date, challenges that lie ahead, overcoming the issues of confusion, sustaining execution, strengthening leadership and policy, the role of quality improvement in health systems strengthening and setting the agenda for learning and next steps. RESULTS Key lessons from the SGS include reducing terminology and methodology confusion, strengthening the learning agenda, embracing improvement science as a means for strengthening health-care systems, developing leadership in improving health care and ensuring that health-care systems focus on patients and communities. A call to action was developed by SGS participants and presented at the 65th World Health Assembly in Geneva. CONCLUSION There is an inarguable need to move improvement in health care to a new level to attain and exceed the Millennium Development Goals. The challenges can be overcome through concerted action of key stakeholders and the application of scientifically grounded management methods to enable the reliable implementation of high-impact interventions for every patient every time needed.

Improving the resilience and workforce of health systems for women’s, children’s, and adolescents’ health

To achieve the sustainable development goals related to maternal, child, and adolescent health, countries need to integrate targeted interventions within their national health strategies and leverage them into financing, workforce, and monitoring capacity across the system, say James Campbell and colleagues.

Lack of toilets and safe water in health-care facilities

This is a major embarrassment for the health sector: health facilities serve as foci for infection and patients seeking treatment fall ill and may die, for the lack of the most basic requirements for good hygiene – safe, reliable water supplies and adequate sanitation. Preg -nant mothers rely on a birthing environment that, at a minimum, does not place them or their baby at risk. Infections cause nearly half of late neonatal deaths (430 000)

Medication Without Harm: WHO's Third Global Patient Safety Challenge

1680 www.thelancet.com Vol 389 April 29, 2017 In 1960, Alphonse Chapanis, turned his attention from engineering to health care. In a study of medicationrelated errors in a 1100-bed hospital, he and his colleague identified seven sources of such errors potentially leading to harm to a patient: medicine omitted, or given to the wrong patient, at the wrong dose, as an unintended extra dose, by the wrong route, at the wrong time, or as the wrong drug entirely. Almost 60 years later, these same types of errors still happen worldwide. Later that year in a follow-up policy paper, Chapanis identified four areas of recommendations that could prevent harm and remain relevant today: written communication, medication procedures, the working environment, training, and education. Indeed, it is difficult to avoid the conclusion that had the recommendations from this revelatory patient safety research been assiduously followed over the past five decades, hundreds of thousands fewer patients would have been killed or seriously harmed by the medicines intended to make them well. Beginning in 2004, WHO, working in partnership with the then World Alliance for Patient Safety, initiated two Global Patient Safety Challenges, Clean Care is Safer Care and Safe Surgery Saves Lives. These challenges mobilised worldwide commitment and action to reduce health-care-associated infections and risk associated with surgery, respectively. At the second Global Summit of Health Ministers on Patient Safety in Bonn, Germany, on March 29, 2017, the Director-General of WHO announced that the Third Global Patient Safety Challenge, Medication Without Harm, would address medication safety. The previous challenges secured strong and early commitment from health ministers, professional bodies, regulators, health leaders, civil society, and health-care practitioners. The action required to deliver the goals of each was broadly similar: an evidence-based analysis of the key problems and solutions; an invitation to WHO member states and other relevant parties to pledge, or sign-up, to address the aims of the challenge; high-profile actions to generate passion and enthusiasm; facilitation Medication Without Harm: WHO’s Third Global Patient Safety Challenge *Neil R Poulter, Daniel T Lackland School of Public Health, Imperial College London, London W12 7RH, UK (NRP); and Department of Neurology, Medical University of South Carolina, Charleston, SC, USA (DTL) n.poulter@imperial.ac.uk

Improving the delivery of safe and effective healthcare in low and middle income countries

Research is needed into creating workable systems that can deliver and sustain interventions

The Third Global Patient Safety Challenge: Tackling Medication-Related Harm

The World Health Organization (WHO) has announced its third global patient safety challenge, (1) which aims to reduce the global burden of iatrogenic medication-related harm by 50% within five years. The intention is to match the global reach and impact of the two earlier global patient safety challenges: Clean care is safer care and Safe surgery saves lives. (2,3) The third challenge, Medication without harm, invites health ministers to initiate national plans addressing four domains of medication safety: engaging patients and the public; medication as products; education, training and monitoring of health-care professionals; and systems and practices of medication management. This challenge also commits WHO to using its convening and coordinating powers to drive forward a range of global actions on medication safety. (4) Here, we focus on three priority areas of medication safety that most affect patients, just as hand hygiene and the surgical checklist were chosen as the flagships of the first two challenges. These three areas are high-risk situations, polypharmacy and transitions of care. Each area is associated with a substantial burden of harm and therefore, if appropriately managed, could reduce the risk of harm to many patients. Certain classes of medications are particularly liable to produce adverse reactions. They tend to have a narrow therapeutic index, meaning that small dosing errors can cause catastrophic outcomes. For example, the use of warfarin for anticoagulation is a high-risk clinical situation involving a medication because its use carries associated risks of bleeding if the international normalized ratio is too high and risks of further thrombosis if it is too low. The Clinical Excellence Commission has summarized high-risk medications in the acronym A PINCH (anti-infective agents; potassium and other electrolytes; insulin; narcotics and other sedatives; chemotherapeutic and immunosuppressive agents and heparin and anticoagulants). (5) However, this classification is not exhaustive; for example, other medications carry risks for those with underlying diseases, such as chronic kidney disease. Focusing on certain key classes of medications has enabled investigators to develop interventions that reduce inadvertent harm caused by these medications. Such interventions can involve low-technology solutions, such as patient medication diaries, or harness the potential of digital technology, as with clinical decision support systems linked with electronic health records. (6) As people tend to live longer, receive treatment for more than one condition at a time and have access to an increasing number of therapeutic options, they tend to take multiple medications. This intake increases the likelihood of drug interactions. Elderly patients may also find it difficult to adhere to complex regimens, increasing the likelihood of patient-induced errors. Progress has been made in identifying medication history and drug-drug combinations that are particularly problematic, enabling risk-stratification and risk-reduction approaches through, for example, de-prescribing initiatives in Canada (7) and the United States of America. …

Measuring quality-of-care in the context of sustainable development goal 3: a call for papers

measures are especially critical given the large scope and increased complexity of health services required. The universal health coverage (UHC) target of the health SDG stipulates that everyone can obtain essential health services at high quality without suffering financial hardship, yet quality has not been widely tracked. 11 There is no benefit to UHC if people are un willing to use services due to the poor quality of the services for which they are financially covered. Even if people are accessing services, poor quality will undermine health outcomes, reducing the value of UHC. Finally, high-quality health services attract the public support that contributes to governments providing sustained financing.