Patient safety is a fundamental principle of healthcare and is now being recognized as a large and growing global public health challenge, according to the World Health Organization (WHO). However, global efforts to reduce the burden of patient harm have not achieved substantial change over the past 15 years, despite pioneering work in some healthcare settings, the WHO noted.

The WHO defines patient safety as a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies, and environments in healthcare that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur. Every point in the process of caregiving contains a certain degree of inherent unsafety, the agency added.

Recognizing the huge burden of patient harm in healthcare, the 72^nd World Health Assembly in May 2019 adopted Resolution WHA72.6 on “Global action on patient safety,” which endorsed the observance of World Patient Safety Day on Sept. 17 of every year and recognized “patient safety as a global health priority.”

Led by the WHO, the annual observance of World Patient Safety Day aims to raise public awareness and foster collaboration between patients, health workers, policymakers, and healthcare leaders to improve patient safety. This year’s theme is “Improving diagnosis for patient safety” with the slogan “Get it right, make it safe!,” highlighting the critical importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.

A diagnosis identifies a patient’s health problem and is vital to accessing the care and treatment patients need. The WHO defines diagnostic error as the failure to establish a correct and timely explanation of a patient’s health problem, which can include delayed, incorrect, or missed diagnoses, or a failure to communicate that explanation to the patient.

Diagnostic errors occur in 5-20% of physician-patient encounters. Doctor reviews reveal harmful diagnostic errors in a minimum of 0.7% of adult admissions. Most people will suffer a diagnostic error in their lifetime, the WHO said.

Aside from diagnostic errors, other common sources of patient harm identified by the WHO include medication errors, surgical errors, healthcare-associated infections (e.g., hospital-acquired pneumonia), sepsis, patient falls, venous thromboembolism (blood clots), pressure ulcers, unsafe transfusion practices, patient misidentification, and unsafe injection practices.

A recent study by Tamondong-Lachica et al identified significant gaps in patient safety performance indicators in select public and private hospitals in the Philippines. Published in January 2024 in the national health science journal Acta Medica Philippina, the study looked at the status of patient safety performance measures and indicators on the international patient safety goals (IPSGs) in 41 level 2 and level 3 hospitals in the country.

Most performance indicators assessed by the study were process measures (52%), while structure (31%) and outcome measures (17%) accounted for the rest. The study found “an obvious lack of structural requirements for patient safety in the hospitals.” Less than half the hospitals included in the study implement risk assessment and management consistently. Reporting of events, near-misses, and patient safety data varied widely among the hospitals. Data utilization for quality improvement is not fully established in many of the hospitals. Patient engagement, which is crucial in promoting patient safety, is not integrated in service delivery and performance measurement in the hospitals.

The study authors recommended the implementation of mechanisms to improve hospitals’ capacity to monitor, anticipate, and reduce risk of patient harm during the provision of healthcare; the adoption by hospitals of a unified set of definitions and protocols for measurement to facilitate reliable monitoring and improvement; and leadership and governance, both internal (e.g., hospital administrators) and external (e.g., Department of Health), that recognize the vital importance of a data-driven approach to policymaking and improvement of service delivery in promoting patient safety.

Most of the mistakes that lead to harm do not occur as a result of the practices of one or a group of health and care workers but are rather due to system or process failures that lead healthcare workers to make mistakes, explained the WHO.

System and organizational factors include the complexity of medical interventions, inadequate processes and procedures, disruptions in workflow and care coordination, resource constraints, inadequate staffing and competency development. Technological factors involve issues related to health information systems, such as problems with electronic health records or medication administration systems, and misuse of technology.

Human factors and behavior involve communication breakdown among healthcare workers, within healthcare teams, and with patients and their families; ineffective teamwork, fatigue, burnout, and cognitive bias. Patient-related factors include limited health literacy, lack of engagement, and non-adherence to treatment. External factors include absence of policies, inconsistent regulations, economic and financial pressures, and challenges related to the natural environment.

To create a safe health system, all necessary measures should be adopted to avoid and reduce harm through organized activities, stressed the WHO. There should be leadership commitment to safety and the creation of a culture whereby safety is prioritized. We need to ensure a safe working environment and the safety of procedures and clinical processes. We should build the competencies of health and care workers and improve teamwork and communication. We need to engage patients and families in policy development, research and shared decision-making. We should establish systems for patient safety incident reporting for learning and continuous improvement.

Investing in patient safety positively impacts health outcomes, reduces costs related to patient harm, improves system efficiency, and helps in reassuring communities and restoring their trust in healthcare systems, said the WHO.

Teodoro B. Padilla is the executive director of Pharmaceutical and Healthcare Association of the Philippines which represents the biopharmaceutical medicines and vaccines industry in the country. Its members are in the forefront of research and development efforts for COVID-19 and other diseases that affect Filipinos.