WHPA Fact Sheet
World Health Professions
Alliance Fact Sheet
Press Release 29 April
2002 - Health Professionals Call for Priority
on Patient Safety
Health care interventions are intended to benefit
the public, but due to the complex combination of processes, technologies
and human interactions there is an inevitable risk that adverse events
will happen. Much evidence has been built on risks in hospitals, however
information about adverse events occurring in healthcare settings such
as physicians’ offices, nursing homes, pharmacies and patients’ homes
are not very well documented. Identifying and reducing the occurrence
of these errors and improving the safety and quality of health care has
therefore been brought forward as a priority issue for health services
around the world.
An adverse event can be defined as harm or injury
caused by the management of a patient’s disease or condition by health
care professionals rather than by the underlying disease or condition
itself. Although human errors may sometimes precipitate serious failures,
there are usually deeper, systemic factors, which if addressed earlier
would have prevented the errors. Hence, the enhancement of patient safety
involves a wide range of actions in the recruitment, training and retention
of health care professionals, performance improvement, environmental safety
and risk management, including infection control, safe use of medicines,
equipment safety, safe clinical practice and safe environment of care.
There is a growing evidence that inadequate institutional
staffing levels are correlated with increase in adverse events such as
patient falls, bed sores, medication errors, nosocomial infections and
readmission rates that can lead to longer hospital stays and increased
hospital mortality rates. In short, inadequate human resources present
a serious threat to the safety and quality of health care.
Some facts and figures about patient safety
- The 1995 Quality in Australian Health Care Study
(QAHCS) found an adverse-event rate of 16.6% among hospital patients.
- The Hospitals for Europe’s Working Party on Quality
Care in Hospitals estimated in 2000 that every tenth patient in hospitals
in Europe suffers from preventable harm and adverse effects related
to his or her care.
- 75% of the adverse drug events in a Utah-Colorado
Study in the United States were attributable to system failures. Most
adverse events were not the result of negligence or lack of training,
but rather occurred because of latent causes within systems.
- In NHS Hospitals adverse events in which harm is
caused to patients occur at a rate in excess of 850,000 a year.
- According to a survey conducted by the Robert Wood
Johnson Foundation, 95% of doctors and 89% of nurses in the United States
have witnessed a serious medical error.
- Poor quality healthcare is responsible for more
than 30% of avoidable deaths in Italy.
The situation in developing countries
In developing countries the probability of adverse
events is much higher than in industrialized nations due in part to the
poor state of infrastructure and equipment, unreliable supply and quality
of medicines, shortcomings in waste management and infection control,
low number and poor performance of personnel because of low motivation
or insufficient technical skills, and severe under financing of essential
operating costs of health services.
- At least 50% of all medical equipment in most developing
countries is unusable, or only partly usable, at any given time.
- In the Newly Independent States, about 40% of hospital
beds are located in structures originally built for other purposes.
As a result the correct infrastructure for radiation protection and
infection control is very difficult to install.
- Approximately 77% of all reported cases of substandard
and counterfeit drugs occur in developing countries.
Adverse health care events carry a high financial
cost. About half of the expenditures for preventable errors are
for direct health care costs.
- The total national cost of preventable adverse
health care events in the United States, including lost income, disability
and medical expenses, is estimated at between US$17 000 million and
US$ 29 000 million annually.
- In the UK the NHS estimates that adverse events
cost £2 billion a year in additional hospital stays alone.
Recommendations for action
Patients and the community
- Inform healthcare professionals of all your
medicines taken and medical conditions.
- Ask questions to clarify information and
increase understanding about health conditions, medicines and
- Make sure to get the results of any test
- Report errors or adverse events to the proper
- Take an active role in assessing the safety
and quality of care in practice.
- Improve communication with patients and other
- Inform patients of potential risks.
- Work to improve practice-related systems.
- Report adverse events to the appropriate
- Strengthen collaboration aspects of drug
Hospitals, clinics, general practice,
drug distribution and other facilities
- Maintaining adequate human resource levels.
- Focus on improving the systems of delivering
care, not blaming individuals.
- Establish rigorous infection control programmes.
- Standardise treatment policies and protocols
to avoid confusion and reliance on memory, which is known to be
fallible and responsible for many errors.
- Avoid similar-sounding and look-alike names
and packages of medication.
- Establish national reporting systems to record,
analyse and learn from adverse incidents.
- Promote a culture of reporting.
- Emphasise safety as a prime concern in health
system performance and quality management.
- Implement mechanisms for ensuring that, where
lessons are identified, the necessary changes are put into practice
and progress is tracked.
- Develop evidence-based policies that will
improve health care.
- Develop mechanisms, for example through accreditation
and other means, to recognize the characteristics of health care
providers that offer a benchmark for excellence in patient safety.
- The International Council of Nurses (ICN) is a federation of national nurses associations, representing the more than 13 million nurses working worldwide. www.icn.ch
- The International Pharmaceutical Federation (FIP) is the global federation of national organisations of pharmacists and pharmaceutical scientists representing more than two million pharmacists around the world. www.fip.org
- The World Medical Association (WMA) is the global federation of national medical associations from around the world, directly and indirectly representing the views of more than nine million physicians. www.wma.net
For further information
World Health Professions Alliance (WHPA)
Dr. Julia Seyer, M.Sc. ,BP 63, 01210 Ferney Voltaire, France
Tel.: 0033 (0) 450 40 75 75 , Fax: 0033 (0) 450 40 59 37
- web: www.whpa.org
Quality of care: patient safety ,World Health Organization Executive Board EB109/9, 5 December 2001 http://www.who.int/gb/EB_WHA/PDF/EB109/eeb1099.pdf (accessed 22 April 2002)
Italy: Better Healthcare could cut
deaths, Reuters Healthcare, January 18, 2002 citing study of
The 2001 Prometeo Atlas of Italian Healthcare.
Health Care Professionals: backbone of
quality and safety of care, Statement of the WHPA
At the WHO Executive Board, 16 January 2001
An Organisation with a Memory, Report
of the UK Department of Health, 2000
http://www.doh.gov.uk/orgmemreport/index.htm (accessed 22 April 2002)
Building a Safer NHS for Patients,
Report of the UK Department of Health, April 2001
http://www.doh.gov.uk/buildsafenhs (accessed 22 April 2002)
Pursuing Perfection, Research conducted
for the Robert Wood Johnson Foundation, March/April 2001. http://www.rwjf.org/news/releaseDetail.jsp?id=1017609851350&contentGroup=rwjfreleases
(accessed 22 April 2002)
To Err is Human: Building a Safer Health
System, Institute of Medicine. November 1999.
29 April 2002