Report from the WHO Global Consultation on Global Patient Safety

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.

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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Nourhan Kawtharani


Nourhan, a quality and safety coordinator with eight years of experience in ambulatory healthcare in Lebanon, aims to deepen her understanding of the systemic and holistic approach to healthcare through this fellowship.

She aims to identify gaps and develop tailored interventions that address specific contexts rather than applying general solutions. Engaging with diverse professionals and perspectives during this educational journey will expand the application of these concepts across different cultural settings.

Nourhan emphasizes the importance of promoting a culture of continuous learning and improvement within healthcare institutions, considering it a vital leadership responsibility to integrate quality and safety initiatives into the organizational culture.

Nourhan's commitment to patient safety and quality management includes sourcing practical resources and transforming insights into actionable knowledge to drive continued progress in healthcare practices and outcomes.

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Elom Otchi


Elom is passionate about improving quality of care and patient safety outcomes.

In view of this, he has had the opportunity to work in various capacities with various organisations including AfIHQSA, WHO, UNICEF and others undertaking research, supporting the development of national quality policies and strategies, facilitating the establishment of quality governance systems across all the levels of the health sector and building capacity of national and sub-national quality leads/teams to institutionalize the practice of quality and patient safety across the continent.

He has also worked extensively across all levels of care in the health sector of Ghana, including leading the Quality & Patient Safety program in its largest teaching hospital.

I would like to use this Fellowship as a learning platform and an opportunity to acquire the requisite knowledge, skills and competencies to complement ongoing efforts by like-minded individuals and organizations to continuously advance improve the quality and patient safety in Ghana and the continent.

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Stephen Taiye Balogun


Stephen is a Senior Programme Officer at the Institute of Human Virology in Nigeria as well as Country Representative for Health Information for All (HIFA).

Stephen plans to use this opportunity to maximise his impact by championing the cause of patient safety and quality in Nigeria and across Africa.

Stephen says "Quality and safety is a major wheel through which universal healthcare coverage can be achieved. The goal is to be a bridge in the gap between the International Quality Improvement and Patient Safety community and my country to ensure rapid spread, adoption, implementation and practice."

We are looking forward to working with both Stephen and our 2020 winner Rhoda Kalondu over the next year.

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Dr Rhoda Kalondu


Rhoda is the Head of the Patient Safety Unit at Kenyatta Hospital in Nairobi and wants to use this Fellowship to learn how to establish a culture of safety and develop systems for assessment and analysis at her institution, and more widely. As well as this, Rhoda intends to develop and execute an intervention to improve patient safety in Kenyatta National Hospital.

It is one thing to institute measures and processes for improvement, but quite another to change the culture of an environment. Rhoda's ambition to lead others in this change inspired the panel.

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Dr Subhrojyoti Bhowmick


I am an MBBS graduate from Calcutta University with a Gold Medal in Gynecology & Obstetrics.

I have completed M.D in Pharmacology from IPGME& R, Kolkata and have over 12 years of experience in the field of Clinical Research, Pharmacovigilance and Medication management in Hospitals.

I have completed certification in Clinical Research Administration & Project Management from Stanford University, USA and in Patient Safety from Johns Hopkins University, USA.

I am an Assessor for National Accreditation Board for Hospitals & Health care providers (NABH), India assessing hospitals for medication safety and clinical quality standards and NABH Assessor for Ethics Committee Accreditation program in India as well.

I serve as the Chairperson, Institutional Ethics Committee of Health Point Hospital, Kolkata and am associated with 2 other Hospital ethics committees as a member.

I finished my Fellowship in Healthcare Quality from the International Society of Quality in Healthcare (ISQua) from Ireland in 2017.

I have published several research articles and have also authored a chapter on “Regulations governing Clinical Trial” in the book “Fundamentals of Clinical Trial & Research”.

I am a peer reviewer for prestigious international journals like the British Journal of Clinical Pharmacology, CNS Drugs and Drug Safety case reports.

I am the recipient of the UK Seth Oration Award for Best Clinical Pharmacology paper by the Indian Pharmacological Society in 2009 and the “Most promising Healthcare professional in Patient Safety in India” award by the Asian African Chamber of Commerce and Industry in October 2018.

Recently in April 2019, I received the Young Quality Achiever award by Consortium of Accredited Healthcare Organizations (CAHO), India for 2019 for my work in the field of medication safety and clinical research.

I have a keen interest in teaching and am visiting adjunct faculty of Pharmacology at KMC, Mangalore, India and for Healthcare technology at MAKAUT, Kolkata, India.

I was associated with Stanford University School of Medicine, in the USA as a Senior Clinical Research Associate from 2015 to 2017 and have certification in Biostatistics, Evidence-based Medicine and Medical Writing from Stanford University.

Currently, I am working as the Clinical Director of Academics, Medical Quality and Clinical Research at Peerless Hospital and B K Roy Research Centre, Kolkata.

I am very happy and thrilled to receive the prestigious ISQua Lucian Leape Patient safety Fellowship Award for 2019 and I look forward to honing my skills further in the field of healthcare quality and patient safety through my experiences during this fellowship.

I sincerely believe that successful completion of this fellowship will help me evolve as a more confident Patient safety leader in India who in turn can provide significant inputs on policy changes through NABH for the Indian healthcare system.

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