Patient Safety: "First, Do No Harm"

The Pan American Health Organization (PAHO) recently hosted the launch of a new World Alliance for Patient Safety, aimed at galvanizing international efforts to reduce illnesses, injuries and deaths of patients receiving health care.

The initiative is being led by the World Health Organization (WHO), whose directorgeneral, LEE Jong-wook, was on hand for the Oct. 27 launch. Partners include PAHO, the Department of Health of the United Kingdom, the U.S. Department of Health and Human Services, and other government and nongovernmental agencies.

Fact sheets prepared for the launch noted that medical errors kill an estimated 44,000 to 98,000 patients in the United States each year—more than the number of deaths due to car accidents, breast cancer or AIDS. In Canada and New Zealand, some 10 percent of hospital patients suffer adverse effects from medical errors, and in Australia, some 16.6 percent.

Data from developing countries are scarce, but experts believe their situation is even worse. WHO estimates that at least 50 percent of all medical equipment is unsafe and that 77 percent of all reported cases of counterfeit and substandard drugs occur in developing countries.

Sir Liam Donaldson, chief medical officer of the United Kingdom and chairman of the alliance, noted that even in richer countries, human error is only part of the problem.

"Adverse events are not just due to human mistakes. The majority are due to underlying factors in the system, such as faulty protocols. If we simply punish staff, the potential for learning from our mistakes will be buried with the patient who died."

Susan Sheridan, vice president of Consumers Advancing Patient Safety, described a series of medical errors that left her firstborn child brain damaged and claimed the life of her husband. She emphasized the importance of incorporating consumers' experiences into patient safety efforts. "Patients know about errors firsthand," she said. "Health care systems have to be responsive to them and provide ways for them to report errors, which can facilitate learning."

Among the priority actions of the new alliance are:

• Addressing healthcare-associated infections worldwide through a campaign titled "Clean Care is Safer Care";
• Developing a taxonomy for patient safety and for reporting adverse events;
• Carrying out research on these issues, particularly baseline studies in developing countries;
• Identifying and disseminating "best practices" for improving patient safety;
• Developing reporting and learning systems on medical errors and "near misses" to facilitate analysis of the root causes of errors and to draw lessons about preventing them;
• Getting patients fully involved in the alliance's work, so that health care providers can learn from their experiences.

"To err is human. To cover up is unforgivable. To fail to learn is inexcusable," said Donaldson.