Patient safety and human factors: international
This section includes notable patient safety programmes, initiatives and practices in place internationally.
World Health Organization (WHO)
World Health Organization (WHO): Patient safety
In October 2004 WHO launched a patient safety programme in response to a World Health Assembly Resolution (2002) urging WHO and Member States to pay the closest possible attention to the problem of patient safety. Its establishment underlined the importance of patient safety as a global health-care issue. This WHO programme on patient safety aims to "coordinate, disseminate and accelerate improvements in patient safety worldwide" and provide a vehicle for international collaboration and action. Each year WHO Patient Safety delivers a number of programmes covering systematic and technical aspects to improve patient safety around the world. View: World Health Assembly Resolution (WHA55.18) and related documents.
A core part of WHO Patient Safety work is related to their Global Patient Safety Challenges. These Challenges are international campaigns which bring together expertise and evidence on important aspects of patient safety and formulate recommendations to ensure the safety of patients receiving care globally. There are currently two Global Patient Safety Challenges.
- Clean Care is Safer Care. This project aims to ensure that sustained hand hygiene improvement remains on the national and international agenda. It includes the Save Lives: Clean Your Hands initiative and audio-visual and printed resources on hand hygiene such as the WHO Guidelines on hand hygiene
- Safe Surgery Saves Lives. The goal of this challenge is to improve the safety of surgical care by ensuring adherence to proven standards of care. The guidance section below has details of some of the specific tools and resources produced by this initiative.
Other key campaign and projects within the WHO programme include:
- Patients for patient safety. Emphasises the central role patients and consumers can play in efforts to improve the quality and safety of healthcare around the world.
- WHO surgical safety checklist and implementation manual. A tool for the relevant clinical teams to improve the safety of surgery by reducing deaths and complications.
- WHO African Partnerships for Patient Safety. This initiative forms part of the WHO response to the increasing commitment and momentum for action on patient safety across Africa. It involves partnerships between African and European hospitals. APPS is focusing first on the prevention of infection in hospitals.
- World Health Organization Europe (2008) Guidance on developing quality and safety strategies with a health system approach. "The aim of this guidance is to help national policy advisers and policy makers to create and implement a national quality strategy, drawing attention to the need for sustainable longer term public health measures, which are sometimes overlooked".
- WHO Patient Safety curriculum guide (2011). The new Multi-professional Patient Safety Curriculum Guide promotes the need for patient safety education to improve the safety of care. The guide assists universities and schools in the fields of dentistry, medicine, midwifery, nursing and pharmacy to teach patient safety. It also supports the training of all health-care professionals on a number of priority patient safety concepts to improve learning about patient safety.
Worldwide
Hong Kong Hospital Authority: Risk Alerts
These risk alerts are issued by Hong Kong's Hospital Authority and include perspectives on safety and good practice examples.
International Society for Quality in Health Care
The International Society for Quality in Health Care, is a non-profit, independent organisation with members in over 70 countries. ISQua works to provide services to guide health professionals, providers, researchers, agencies, policy makers and consumers, to achieve excellence in healthcare delivery to all people, and to continuously improve the quality and safety of care.
International Council of Nurses (ICN)
The International Council of Nurses (ICN) is a federation of more than 130 national nurses associations (NNAs), representing the more than 13 million nurses worldwide. View the ICN Position statement on patient safety. The ICN has a number of factsheets including some World Health Professions Alliance ones which are available in this alphabetical listing under the heading Patient safety.
Health Quality and Safety Commission New Zealand
The Commission works with clinicians and providers of health services to improve the quality and safety of health and disability services in New Zealand.
World Alliance for Patient Safety
Launched in October 2004 the Alliance brought together heads of agencies, health policy-makers and patient representatives with the World Health Organization with the aim of advancing the patient safety goal of "First do no harm", and reducing the adverse health and social consequences of unsafe health care. Potentially the alliance can "provide a mechanism to decrease duplication of investment and activities and benefit by economies of scale".
USA
Agency for Healthcare Research and Quality: Quality and Patient Safety PSNet
The Agency for Healthcare Research and Quality's (AHRQ) mission is "to improve the quality, safety, efficiency, and effectiveness of health care for all Americans". In particular the AHRQ has taken a national lead in developing tools and resources to combat medical errors and improve patient safety. Resources include the AHRQ PSNet (Patient Safety Network) which makes available 'Patient Safety Primers' and a regular email newsletter on patient safety information.
Anaesthesia Patient Safety Foundation
The APSF's Mission is to improve continually the safety of patients during anaesthesia care by encouraging and conducting: safety research and education; patient safety programs and campaigns and national and international exchange of information and ideas.
Institute for Healthcare Improvement (IHI)
The IHI is an independent organisation which is based in the USA but works with health professionals throughout the world and is a partner in a number of safety initiatives within the UK. The Patient Safety topic area provides links to patient safety improvement measures; tools; audio and video content.
Institute for Safe Medication Practices (ISMP)
An American organisation devoted entirely to medication error prevention and safe medication use. The Institute runs an educational programme including teleconferences and hosts a 'Safety Talk' forum. The website includes FAQ's on issues around medication error and medication safety newsletters.
Institute of Medicine (IoM)
The Institute of Medicine (IOM) is an independent, nonprofit organisation that works outside of government to provide unbiased and authoritative advice to decision makers and the public. IOM's report 'To err is human' examines the extent and causes of medical error. It set out a comprehensive strategy for government and industry to reduce medical errors and calls for the creation of a national patient safety centre to develop the systems needed to address the problems.
National Patient Safety Foundation
A leading American organisation dedicated to improving patient safety which provides links to resources produced by the Foundation and other organisations. It hosts a patient safety discussion forum, has a research programme and publishes the Journal of Patient Safety.
National Quality Forum - Patient Safety
The National Quality Forum (NQF) is a not-for-profit membership organization created in 1999 to develop and implement a national strategy for health care quality measurement and reporting. The NQF has focused on several patient safety areas including: error rates, unnecessary procedures and under treatment, especially preventive care.
Partnership for Patient Safety (P4Ps)
Partnership for Patient Safety is a patient-centred initiative based in the USA. It aims to "advance the reliability of healthcare systems worldwide" and to achieve this by working in partnerships and joint ventures which share the same values and objectives.
Patient Safety Organization - CECRI Institute PSO
ECRI Institute is an independent nonprofit organisation that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care.
The Joint Commission: Patient Safety
The Joint Commission is a major accrediting body in health care in the USA maintaining standards that focus on improving the quality and safety of care provided by health care organisations. The Commission has a commitment to improving healthcare safety and the website provides information about safety standards, initiatives and resources to support these.
VA National Center for Patient Safety
The NCPS was established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration. Their goal is the nationwide reduction and prevention of inadvertent harm to patients as a result of their care.
Australia
Australian Patient Safety Foundation
APSF is dedicated to the advancement of patient safety and provides leadership in the reduction of harm to patients in all health care environments. Through its subsidiary, Patient Safety International (PSI), the APSF provides a software tool, the Advanced Incident Management System (AIMS®) to capture information from a wide variety of sources to enable "de-construction" and classification of incidents from "near misses" to "sentinel events" in a consistent way, so that subsequent, detailed analysis is possible.
Australian Commission on Safety and Quality in Health Care
The Australian Council for Safety and Quality in Health Care was established by Australian Health Ministers to lead national efforts to improve the safety and quality of health care provision in Australia. Working closely with other national bodies, it reports annually to all Health Ministers and is supported by all State and Territory jurisdictions.
Centre for Research Excellence in Patient Safety
The Centre of Research Excellence in Patient Safety was established to design, conduct and promote high quality multi-centre research to improve quality, safety, efficiency and effectiveness of health care for Australians. They have undertaken research and patient safety initiatives locally and internationally. Their research has focussed on four main areas: the use of data to monitor quality of care; improving information transfer; reducing medication error and patient safety.
University of South Australia (UniSA): Human Factors and Safety Management Systems
UniSA hosts one of Australia's leading research and teaching programs in the areas of Human Factors and Safety Management Systems, including system design in healthcare.
Canada
British Columbia Patient Safety and Quality Council (BCPSQC)
The British Columbia Patient Safety and Quality Council (BCPSQC) provides system-wide leadership that brings a provincial perspective to patient safety and quality improvement activities in British Columbia. Through collaborative partnerships with health authorities and other health care providers, BCPSQC promotes and informs a provincially coordinated, patient-centred approach to patient safety and quality improvement. BCPSQC also provides advice to the Minister of Health Services on issues of patient safety and quality of care.
Canadian Patient Safety Institute (CPSI)
The Canadian Patient Safety Institute (CPSI) provides a coordinating and leadership role across health sectors and systems, promotes leading practices and raises awareness with stakeholders, patients and the general public about patient safety.
Patients for Patient Safety Canada
Patients for Patient Safety Canada (PFPSC) is a patient-led program funded by the Canadian Patient Safety Institute. They champion the patient's voice to advance safe healthcare.
Safer Healthcare Now!
This programme is part of the Canadian Patient Safety Institute, and it invests in frontline providers and the delivery system to improve the safety of patient care throughout Canada by implementing interventions known to reduce avoidable harm.
Europe
European Network for Patient Safety (EUNetPaS)
The European Network for Patient Safety (EUNetPaS) project established an umbrella network of all 27 EU Member States, international organisations, and stakeholders in the field of healthcare to encourage and enhance collaboration in the field of patient safety. The objectives of the project were to promote coherence at the EU level through recommendations and common tools, promote a patient safety culture based on no-blame reporting, promote education and information on patient safety and to create a permanent collaboration network on patient safety.
European Commission Health-EU: Patient safety
Patient safety is a special topic within the public health area of the European Commission website. The patient safety pages provide links to documents and other resources about policy actions at EU level.
European Network to promote infection prevention for patient safety
This network aims to promote infection prevention for patient safety across Europe.
Improving Patient Safety in Europe (IPSE)
IPSE aims to resolve persisting differences in the variability of preventive practices and outcomes with respect to nosocomial infection and antibiotic resistance in Europe.
WHO Europe: Patient Safety
WHO Europe supports the 53 Member States in the WHO European Region in developing and sustaining their national health policies, health systems and public health programmes; working to identify, prevent and overcome potential threats to health; anticipating future challenges; and advocating public health. Health topics include patient safety.