For World Patient Safety Day 2022 on September 17 we got in touch with Professor Sir Liam Donaldson. He is the World Health Organisation’s Envoy for Patient Safety as well as Professor of Public Health at the London School of Hygiene and Tropical Medicine. Previously, he served as the United Kingdom’s Chief Medical Adviser and as England’s 15th Chief Medical Officer.

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Video Interview

Podcast Interview

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Transcript

Why was there the need to establish a World Patient Safety Day, and what did it take for the idea to come to life?

Patient safety has been a priority for health care systems around the world for some considerable time now. A recognition that the level of avoidable harm is too high and it needs to come down. And health care worldwide has been less successful in reducing the risks in its care than, for example, other high-risk industries like the airline industry, who have had a very good safety record and an improving record over the last two or three decades.

So, there was a need to re-energize and draw much more attention to the concept of avoidable harm in health care and get underway more programs of action in patient safety to try and reduce the risks of care. And with all of that in mind, a group of health ministers got together a few years ago, led by the United Kingdom’s health secretary at the time, Jeremy Hunt, to convene discussions amongst health ministers in a series of summits. And one of the ideas that came out of that was from the health ministers, and particularly Jeremy Hunt, the UK health minister, to have an annual World Patient Safety Day in a similar way to the way that other global health programs, for example, tobacco control have a No Smoking Day. And there are many, many other examples, but patient safety at the time did not have that same high profile. So, in advocating for it, these ministers were very successful.

Ultimately, the World Health Assembly, the annual policymaking forum of the World Health Organization, agreed that there should be a World Patient Safety Day. And we’ve had a few of them now. They’ve been very successful in drawing attention to the challenge of making health care safer worldwide.

Please tell us more about the resolution WHA72.6 – “Global action on patient safety” as well as its background and impact.

The concept of a resolution, for people that don’t know too much about how the World Health Organization functions: Each year there is a World Health Assembly which brings together all the countries, more than 190 countries of the world, and they’re represented at very senior level by their health ministers. All sorts of other people attend: NGOs, experts, commentators. And so it’s a very, very big meeting held in Geneva, Switzerland. And prior to that meeting, there are proposals made to a smaller body, an executive committee of the World Health Organization, which includes its director general and is chaired by a health minister from one of the member states, to look at a range of proposals that have come up through the system for new policies in particular fields. For example, maternal and child health, HIV, AIDS, nutrition, vaccines. And those are scrutinized by the executive committee. And then a certain number of them are recommended to go through for the approval of policymakers at the big annual World Health Assembly.

The resolution on patient safety was developed over quite a long period of time, two years, by the WHO’s team on patient safety, but also involving many experts, many representatives of member states, very wide consultation. Finally, it was approved by the World Health Assembly, but essentially the resolution was to commit all of the countries, all of the member states in the World Health Organization to give priority to improving the safety of care within their health system and to adopt a range of actions to do that. And World Patient Safety Day was one of the strands in the resolution, but there were many others as well. It’s the first time that such a comprehensive resolution has ever been agreed to tackle this challenge of improving the safety of care all around the world.

It’s important to recognize that although unsafe care happens to a degree in every health care system, the context is very different in different parts of the world. For example, in the low income countries in Africa, they’re struggling with poor infrastructure. They don’t have good access to care. The patients don’t have good access to care. And often levels of equipment and technology are not there to the extent that there would be in in a high income country like the UK or Europe or the USA. So, their concept of how to deliver safe care is very different. It’s much more about doing the basics, making sure that the patients who are seriously ill get somewhere to be treated, they aren’t financially ruined by the illness that they have, the staff are able to deal with the problem, albeit not maybe in using such high technology and medications that could be used in a high-income setting. But nevertheless that they do their best within the resources available to them to make the care as safe as it can be, given the constraints.

So, the resolution wasn’t just targeted at the places who’ve done most work on trying to improve safety. It tried to give a prescription for everybody into how they might tackle it, bearing in mind the very diverse contexts in which health care is delivered in different parts of the world.

What is the Global Patient Safety Action Plan 2021–2030, and how would you describe its goals?

Its goals are really to start by tackling what has become quite a controversial debate in health care, looking for the goal of zero harm, zero avoidable harm. And it’s controversial as an overarching goal because people say: “Well, you can never get to zero. Health care is so complex that it is often delivered in pressurized environments. And it’s unrealistic to think that you can eliminate all avoidable harm.”

So, we had a very extensive debate in producing the early stages of this action plan on whether everybody would agree to have a goal of zero avoidable harm. And I think we came to quite a good solution. I think nobody wanted to launch a plan that was impossible to deliver because it would demoralize everybody and people couldn’t feel motivated and committed to it. At the same time, we didn’t feel it was acceptable to say that certain harm is inevitable, because that takes away the motivation to do what everybody should be doing for their patients and give them the maximum protection that we can from some of the things that inevitably will threaten the safety of care.

I think we came up with quite a good option in that we didn’t say that we had a goal of avoidable harm in a technical sense, but we said we wanted everybody to approach their work, whether they are planning or leading services or delivering care as a practitioner, with a mindset that they were trying to do their work in a way that would avoid harm. We know that we won’t be able to get to zero harm in a technical sense, but we could get to a position where everybody in every health system in the world has a fundamental value, that they approach everything they do with the aim of preventing harm to their patients. So, that is probably the most important thing about the plan. It creates a culture, an attitude, a way of working, which is very, very patient-centered.

Then there are different elements to it which set objectives in particular areas, for example, ensuring that the best research evidence and information is available that can be used to monitor progress and target particular problems. There’s a very strong part of the strategy that is about enabling patients and families to play a big part in the program, and that’s been a feature of the WHO’s Patient Safety Program ever since I’ve been the Envoy for Patient Safety. We’ve had a program called Patients for Patient Safety, which includes many families whose members have been victims of harm, perhaps have died due to an unfortunate error.

Those people command huge respect because they’ve overcome grief and the trauma of perhaps losing a loved one. But they’ve set themselves to help us in the health systems of the world to improve. So, when they tell their stories about what happened to their family member who was involved in an incident where they were harmed or even died, then I’ve observed when I’ve watched them telling their stories to audiences of health care workers and policymakers, that they move the heart in a way that a presentation from somebody like myself, a doctor, would not be able to do. They light up the emotion and the compassion that’s within the heart of every health care worker who wants to do their best and gives them, I think, a connection to what avoidable harm means in real people’s lives. And I think that’s a very precious part of the strategy which we want to ensure in the implementation is given a great deal of emphasis: the direct engagement and connection to patients and families.

“Medication Safety” has been selected as the theme for World Patient Safety Day 2022, along with the slogan “Medication Without Harm”. Why did you choose these in particular?

It has to do really with two things. One, the size of the particular safety problem. I mean, sometimes the technical description of that is the burden of harm or the burden of disease. And medication safety, when you look at the different causes of unsafe care, they range from things like the wrong surgery being conducted on a patient to possibly falls from patients who are not being supervised in an elderly care setting and injury resulting from that, across a wide range of categories. But when those categories are all added up, then overall errors and unsafe actions involving medicines account for about 40%. So, the burden of harm is a big category and it does need to be tackled.

I think the second thing is that we like to choose something that is recognizable to the public around the world, that it makes sense to them and they can see why we’re trying to do things. And if you just think very generally about medication, it’s probably about the only aspect of health care which would apply to virtually everyone in the world. Maybe there are a few people who live their lives, never having taken a tablet or having had an injection. But there must be very few. So, the safety of the medication that you’re given as a patient affects everybody’s lives. Billions and billions of people around the world. And so that’s another reason why there’s a connection between World Patient Safety Day at a global level and the individual living anywhere in any community in the world.

Finally, I think it’s a good topic because we understand the causation of errors and harm in medication much better than other fields because it’s been very extensively studied by researchers. For example, we know that some errors occur because different drugs are packaged and labeled and have color coding in very similar ways, even though they’re entirely different in their effects, so that, for example, in an urgent situation, a nurse could be reaching for the package to get the medicine out and give it to the patient through an injection or an intravenous line. And she could inadvertently pick up the wrong medicine. And that has happened and does happen around the world.

And that’s why we sort of enter another slightly controversial area there, because there has been a tendency, particularly with errors involving medication, to blame the health care worker for making the mistake. The whole philosophy of programs in patient safety, including the global Patient Safety Action Plan and all the work that’s been done, is that it should be rare to blame an individual unless they’re absolutely negligent. Most errors occur because of good people working in a weak system. The example I’ve given you of the packaging and labeling of medicine, that is the reason that the nurse makes the error, not because she is careless.

We have to get away from a situation where there is a blame culture and individuals are disciplined or even charged with criminal charges for making errors where really they weren’t negligent. It was the design of the system and processes of care which provoked them to make an error.

Having this topic as World Patient Safety Day is also a way of highlighting that area, of ensuring that people realize that many mistakes are honest mistakes. We need to work very hard to design processes of care and care environments and health products which don’t make them error-prone. And in that way, we stop the devastation that occurs to patients when they’re the subject of a serious error involving medicine, but we also protect our very conscientious and caring staff from being accused of something which really wasn’t their fault, even though they were involved in it.

What are your plans for World Patient Safety Day 2022 on September 17?

We’ve learned a lot from the previous World Patient Safety Days. Some of the past ones have involved topics like last year’s, which was maternal and child care, the year before that, which was coming out of the pandemic, it was health worker safety because a lot of attention had been drawn to the risks that courageous health care workers around the world had taken in going into environments, often with insufficient protective clothing, and subjected themselves to risk. And indeed, some of them died.

Each of the topics has highlighted something that’s really important. And so, above anything, as I see it, the activities of World Patient Safety Day are an opportunity for clinical care teams around the world, as well as policymakers and as well as patient groups to highlight and showcase the work that they’re doing, and sometimes to enable them to be empowered in their own countries to do more of the work they’re doing, because sometimes they’re hidden from view. Their bosses don’t even know about the good things that they’re doing. It’s an opportunity to get all of that into the open and celebrate not just the commitment and passion that such people have, but also some of the results they’re achieving so that we can share good practice and ensure that people in different parts of a country or different parts of the world can learn from each other’s experiences.

Many thanks for your time and for the interview.