6th Annual World Patient Safety, Science & Technology Summit
Dr Tedros Adhanom Ghebreyesus
Director-General of the World Health Organization
Your Excellency Jeremy Hunt, Secretary of State for Health and Social Care,
Joe Kiani, Founder and Chairman of the Patient Safety Movement Foundation,
Earlier today I told him, you must be crazy to start a movement. He admitted he’s crazy. We need more crazy people like him to start a movement and change the world.
Sir Liam Donaldson, colleagues, friends, ladies and gentlemen,
I’d like to start by thanking you for the invitation to come and speak to you at this very important meeting.
This Summit is a vital forum for bringing together hospital leaders, patient advocates, policymakers, government leaders, and the health care industry to discuss challenges, innovative new programs and best practices to prevent medical errors and take urgent action to improve patient safety.
And I’d like to congratulate you my brother Jeremy, for your leadership on this issue as a global ambassador for patient safety, and for initiating a series of annual “Global Ministerial Summits” to build political momentum for global patient safety.
You are all familiar with the famous principle that in medicine, a doctor’s primary responsibility is “first do no harm”.
No one should be harmed while seeking care.
But unfortunately, we know this is not the case.
I think of the 21-year-old man who died because the cancer drug he was given was mistakenly injected into his spine, instead of his vein.
The 79-year-old woman who was prescribed so many medicines she developed drug-induced Parkinson’s disease.
And the 8-year-old boy who died in his sleep after being given the wrong medicine just before bed. A pharmacist had mistakenly dispensed a powerful muscle relaxant that looked and tasted the same as the drug the child was supposed to take for a sleep disorder.
If only these were isolated incidents.
But the reality is that every year, millions of patients die or are injured because of unsafe and poor quality health care. Most of these deaths and injuries are totally avoidable.
Adverse events are now estimated to be the 14th leading cause of death and injury globally. That puts patient harm in the same league as tuberculosis and malaria.
There are an estimated 421 million hospitalizations in the world every year, and on average, 1 in 10 of those results in adverse events.
This is a frightening statistic. Especially when we know that at least half of adverse events could be prevented.
Of course, the odds are not the same everywhere. In a high-income country like the UK, with an advanced health system, the rates of medical error are much lower.
Although you have recently had some instances of patient harm that highlight the need for continuous improvement, the reality is that the UK is a global leader in patient safety.
Last year, a study of high-income nations ranked the UK as the top-performing health system overall, and the top performing health system on patient safety.
But the UK is saying the situation we are in is unacceptable, and we have to go for zero preventable deaths. That should be the indicator.
As usual, it is the poorest, most disadvantaged communities that suffer the most. Two-thirds of adverse events occur in low- and middle-income countries.
They are the last to benefit from advances in medicine, but the most likely to suffer the consequences of medical errors.
This harm takes many forms.
People are harmed when health workers fail to clean their hands at the right moments, using the right technique.
People are harmed when injections are given using syringes that have simply been rinsed and re-used to save money.
People are harmed when medicines are mixed up, or given in the wrong dose, or at the wrong time.
People are harmed when wrong procedures are followed before, during and after surgery, or the wrong blood is transfused, or something as simple as the wrong gown is worn.
The good news is that there are solutions to each of these situations. WHO has evidence-based guidelines, checklists and other tools that can be used to protect patients and health workers from harm.
The needless suffering of patients and their families is bad enough. But each adverse event erodes the most precious resource in health care, and that’s trust.
When people aren’t sure whether it is safe to seek care, they will cease to seek care.
They will stay at home, where their condition will get worse, or they will infect others, creating a greater burden of disease, and greater costs for the health system.
We saw this with devastating clarity during the West African Ebola epidemic in 2014 and 2015.
Because of the perception that health services were unsafe – and in some cases they were unsafe – many of those infected chose to stay at home.
This created pockets of disease that spread through communities, with tragic consequences.
This is why we say that universal health coverage and health security are two sides of the same coin. When health services are not available, or not affordable, or not safe, the conditions are ripe for disaster.
And of course, the economic costs of medical errors are astronomical.
About 15% of all hospital activity and expenditure is a direct result of adverse events. And the costs of treating safety failures amount to trillions of dollars each year.
Here in the UK, the cost of excess patient days due to patient injuries has been estimated at more than 1 billion pounds.
Let me put it simply: medical errors aren’t just bad medicine; they’re bad economics.
The investments needed to improve patient safety pale into insignificance compared with the costs of harm.
The question, therefore, is not whether we can afford the interventions that will keep patients safe. The question is whether we can afford the status quo.
This is especially true in the case of medication-related harm.
As Jeremy has said, medication-related harm is one area of patient safety where we can and must make a difference.
Globally, the cost associated with medication errors alone has been estimated at US$42 billion annually.
Last year, WHO took action to address this major public health challenge by launching a global Medication Without Harm campaign that aims to reduce severe, avoidable medication-related harm by 50% over five years, as Jeremy indicated earlier.
We are aiming to address the weaknesses in health systems that lead to medication errors and the severe harm that results.
The reasons for medication errors are many. Some medicines look the same or sound the same. Sometimes patient’s identities are mixed up and the wrong drug is given to the wrong person. Sometimes mistakes are made in calculating dosing.
But there are ways to avoid all these errors. The Medication Without Harm campaign aims to improve the way medicines are prescribed, distributed, administered and consumed, and increase awareness among patients about the risks associated with the improper use of medication.
Our message is simple: know, check, ask.
Patients must know their medication, check that it’s the right dose and ask their health provider if they are unsure.
Health providers must also know their medication, check that they have the right drug, at the right dose, for the right patient at the right time, and ask the patient if they understand.
Know. Check. Ask.
WHO is actively engaging countries to commit to the challenge and take urgent action on medication safety.
To support countries, we’re developing guidance to reduce harm that results from high-risk medicines and situations, patients who take multiple medications, and transitions of care, which is often when mistakes are made.
We’re creating tools to inform patients about the risks, and empower them to become more active participants in their own care.
We’re developing a medication safety curriculum for the education of health care professionals.
And we’re defining research priorities to engage academic and research institutions.
Medication errors do not only cause harm to the individual patient. They can also fuel the spread of antimicrobial resistance.
Recently, WHO published the first report from our Global Antimicrobial Surveillance System, known as GLASS. The findings are alarming.
In some countries, up to 82% of bacterial infections are resistant to at least one of the most commonly-used antibiotics.
Medication errors are part of that story.
When antibiotics are wrongly prescribed, or are not taken correctly, it is not just the patient’s health that is at risk. It’s all of us.
Ladies and gentlemen,
There is no silver bullet for patient safety. There are no short cuts, no quick fixes.
But let me give you five building blocks that together create the environment in which errors can be avoided and people can be kept safe.
First, and most importantly, committed leadership is important. Jeremy and Joe have already said it, and Sir Liam too. Both at the national level and at the level of each individual health facility, we need leaders who will create a culture that puts patient safety at the apex of clinical care. Leadership to lay the right culture.
Just as the aviation industry has made passenger safety its highest priority, and the construction industry has put a premium on the safety of workers, so patient safety must become part of the DNA of health care. That takes political commitment from the highest levels.
Second, clear policies. Every health worker must know and understand the best practices, based on the best evidence, for keeping patients safe.
This includes clear policies on reporting and learning from medical errors, and what to do about them when they happen. A vital part of this is to create an open culture that increases the incentives for reporting adverse events and errors, and removes the incentives for hiding them.
In that regard, I also commend the UK for establishing a system for blame-free reporting, and a learning system. This is the kind of leadership that is crucial for creating a patient safety culture.
Third, data driven improvements. Robust data systems are vital for tracking what’s working and what’s not, so that we can learn and make adjustments continuously.
Fourth, competent and compassionate health professionals, in sufficient numbers. This is vital. Policies and systems are important, but in the end, health services are delivered by people -- humans.
Very often, harm happens not because of incompetence or neglect, but because health workers are tired and overworked, health facilities are overcrowded, or because of staff shortages, poor training or the wrong information being given to patients.
We must therefore give all health workers the conditions, the skills, the training and the tools to do their jobs to the best of their ability.
And fifth, we must involve patients and their families as true partners in care. Too often health services are delivered in a way that makes people passive recipients of their own care, instead of active participants.
When people are empowered to take charge of their own care, when they are listened to, informed and consulted, when their needs and preferences are respected, the odds of errors and harm are dramatically lower.
This is what we mean by people-centred care. It is one of the foundations of patient safety. And it is one of the hallmarks of the world’s best health systems.
As you know, there is no higher priority at WHO than universal health coverage, built on the foundation of health systems that deliver people-centred care.
Ensuring that people can access health services that are safe, effective, affordable and of good quality, without facing financial hardship, is one of the best investments a country can make.
It’s not only an investment in better health, it’s a platform for stable, equitable and prosperous societies.
This year is WHO’s 70th birthday. We were founded in 1948 on the conviction that health is a human right, not a privilege.
And by a happy coincidence, this year is also the 70th birthday of the National Health Service here in the UK.
In many ways, the NHS is the embodiment of WHO’s vision, and is living proof that with political commitment, universal health coverage is not a pipedream; it can be a reality.
I know the NHS is not perfect. No health system is, or ever will be.
I know you face challenges and constraints.
I know that recently several incidents have focused attention on patient safety here in the UK. This is a good thing – it shows that patient groups, advocates and the media are doing their jobs.
Again Jeremy, I congratulate you for the steps you are taking to ensure the UK learns from these experiences, and puts measures in place to ensure they are not repeated. The transparency you’re introducing into the system --- that’s the basis for continuous improvement.
But for 70 years, the NHS has been ensuring that access to health services is a right for all Britons, rich and poor.
You are a role model for the world.
That’s why I’m proud that WHO and the British government are working together to improve patient safety in low- and middle-income countries by building leadership and the human resources to make a difference.
Ladies and gentlemen,
We all know that to err is human. But it is also human to care. It is human to want to do better. It is human to do our best to keep our brothers and sisters safe.
As leaders, you have the power to affect change that saves lives and prevents needless suffering.
You have the power to make sure no one is harmed while seeking care.
Those of you in industry can harness the power of innovation to develop technologies and tools that make health care safer and more cost-effective, as Joe said earlier.
Those of you who run hospitals can establish a positive safety culture by breaking down the structures that inhibit reporting, and creating multi-disciplinary teams that provide safe, people-centred care.
Those of you in government can put in place clear policies, based on the best evidence, to reduce the risk of harm, prevent adverse events and errors, and ensure that when they do happen, they are reported in a blame-free culture.
Those of you who are advocates can continue using your voices to raise awareness of these issues, and to keep us all accountable.
Everyone has a role to play.
Together, we must build strong leadership to create a safety culture and an open environment for blame-free reporting;
We must engage patients and families in their own care, and foster better interaction between patients and providers;
And we must share best practices and successful models.
At the beginning of my remarks I gave you three examples of people who were harmed or killed because of medical error.
Each one is a tragedy, but each one has led to change that will help prevent the same thing from happening to someone else.
The incident involving the 21-year-old man who died because his cancer medication was wrongly administered led to changes that reduce the room for error. And a campaign called “Just Bag It” urges hospital pharmacies to prepare the drug in question in a small drip bag instead of a syringe.
The 79-year-old woman’s daughter researched her mother’s condition and realized she might have been suffering from drug-induced Parkinson’s disease. Once she was taken off the medicines, the symptoms disappeared.
And the parents of the 8-year-old boy who died in his sleep have begun a campaign to improve reporting of medication errors.
Every instance of patient harm is a tragedy. But it’s a worse tragedy if we do not learn from them, and resolve that the same thing will never happen again.
Let me assure you that WHO is committed to the safety of every patient, by working with countries to put in place systems, processes and practices for ensuring safer care.
We’re committed to working in close collaboration with the Patient Safety Movement Foundation and other partners to ensure zero preventable deaths by 2020. I join Jeremy to thank Joe for bringing us here together, and I also thank Jeremy for his leadership on this.
We share the same vision: that no lives are harmed or lost during the provision of health care.
Together we can change the tide.
Thank you so much.