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By Shin Ushiro, ISQua Board Member Thursday. Mar 5, 2020

Report from the WHO Global Consultation on Global Patient Safety Featured

In May 2019, WHO approved the resolution on Global Patient Safety Action on Patient Safety in the 73rd WHO Assembly (WHA). This resolution was developed under the strong leadership of Dr Tedros Adahanom Ghebreyesus WHO-DG; R.H. Jeremy Hunt, former Secretary of State for Health, UK; Sir Liam Donaldson, WHO Patient Safety Envoy; and many other passionate leaders through the previous Ministerial Summits on Patient Safety.


These Ministerial Summits have been held in the UK, Germany, Japan and Saudi Arabia, and ISQua was in attendance as a relevant and global NGO. It is of note that the resolution includes the foundation of the “World Patient Safety Day” to be observed on 17th September each year.


Member countries were increasingly required to work on patient safety in a globally concerted manner in the wake of this approval. 


In order to specify working agendas for the resolution, experts, including three board members from ISQua - myself, Dr Peter Lachman, CEO; and Dr Ezequiel Garcia Elorrio gathered in Geneva from 24th - 26th February 2020 to help produce a draft agenda on patient safety toward 2030 called “A Decade of Patient Safety 2020-2030”.


This flagship initiative by WHO to promote patient safety aims at recruiting political commitment to gain and maintain continuous momentum for it. Participants and relevant WHO departments believe that patient safety should be achieved as a core part of the development of Universal Health Coverage (UHC), which is one of the Sustainable Development Goals (SDGs) proposed by the United Nation. 


It was interesting to see the history of patient safety described by Dr Neelam Dhingra, Coordinator, Patient Safety and Risk Management,WHO; in a conceptualized chronological manner such as ”Foundation (1998-2012)”, “Rejuvenation (2015-2018)”, “Watershed (2019)” and “Vision (2020-2030)”.


Twelver pillars where provisionally presented in advance by WHO for the discussion:


Theme 1: Safety in patient care, clinical processes and use of medical products and devices (for example: medication, surgery, immunization, blood transfusion, radiation, injections, medical devices, mental health, prevention of falls and venous thromboembolism, primary care, emergencies and fragile conditions)

Theme 2: Patient safety policy and priorities

Theme 3: Leadership and patient safety culture

Theme 4: Sufficient competent and compassionate workforce: Patient safety education and training

Theme 5: Human factors capability and capacity, and workforce and workplace safety

Theme 6: Measurement, reporting, learning and surveillance

Theme 7: Patient safety research and innovation

Theme 8: Global Patient Safety Challenges

Theme 9: Patient engagement and empowerment

Theme 10: Patient safety in an era of universal health coverage: Safety and quality across the continuum of care

Theme 11: Developing network and partnerships

Theme 12: Water, sanitation and hygiene, infection prevention and control, and anti-microbial resistance


The three ISQua board members made presentations on Day1 in relation to the themes, and chaired or intensively joined the working groups on the themes in Day 2. 


I chaired Group 7 with Professors Hardeep Singh, US and Paulo Sousa, Portugal which carried the theme “Research & Innovation”. What was unique about the compiled presentation at the end of Day2 on this theme was the engagement of the patient in research projects and mobilizing research fund provided by huge private sector organizations.


Building a network of patients on a global basis was also highlighted and praised by participants. WHO has operated “Patient for Patient Safety” aiming at the same goals.


It occurred to me that ISQua may provide the opportunity to enhance the network on global stage. I would like to stress that ISQua was often mentioned in the meeting as an official partner of WHO in anticipation of commitment to bringing expertise to fulfil the goals of the initiative. 


On Day3, the final day, participants presented various views as further inputs to the compiled ideas on Day 2.  They drew attention to the litigation issue on the agenda.


R.H. Jeremy Hunt touched on this in his presentation on the incidence of disabled babies cared for by the NHS, England and the compensation system in Japan. Even LMICs mentioned a similar issue as citizens are no longer silent in LMICs when they or their family members are disabled through healthcare.


Therefore, I described No-fault Compensation/Investigation/Prevention System for Cerebral Palsy i.e. case of baby with brain damage; operated by the Japan Council for Quality Health Cate (JQ) which is successful in reducing litigation burden and observed penetration of safer knowledge and procedures of delivery and declining statistical trend of profound cerebral palsy. I assume “Maternal Safety” would be included in the WHO flagship initiative.


Dr Edward Kelly gave a 40-minute presentation on the final day to provide an update on the progress relevant to this meeting on the WHO primary healthcare measurement project for patient safety, in which mapping and alignment of existing frameworks indicators are being conducted.


The draft plan to be created, in reference to inputs from experts, will be processed orderly through regional member state consultation and online public consultation before it is submitted to WHA 74 for final approval. 


Dr Tedros joined the meeting at the close, amid hectic schedule related to COVID-19 outbreaks, and delivered a speech to display the WHO's clear intention to promote patient safety by building a robust framework toward 2030.


We also all thanked Sir Liam Donaldson for chairing the three day long sessions with intensive discussions.



Shin Ushiro, ISQua Board Member


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