GLOBAL PATIENT SAFETY ACTION PLAN 2021–2030 Towards Eliminating Avoidable Harm in Health Care Second Draft November 2020 Table of Contents Overview of the Global Patient Safety Action Plan 2021–2030 ................................................................................................................v Abbreviations ............................................................................................................................................................................................................vii 1. Introduction .........................................................................................................................................................................................................1 Background .................................................................................................................................................................................................1 The emergence of patient safety thinking .....................................................................................................................2 The global burden of unsafe care ......................................................................................................................................2 The evolution of the global patient safety movement ..............................................................................................3 COVID–19: A broader concept of avoidable harm ......................................................................................................6 Mandate .......................................................................................................................................................................................................6 Development process .............................................................................................................................................................................6 2. Vision, Mission and Goal .................................................................................................................................................................................8 3. Guiding Principles .............................................................................................................................................................................................9 Engage patients and families as partners in safe care .................................................................................................................9 Achieve results through collaborative working ............................................................................................................................9 Analyse data to generate learning......................................................................................................................................................9 Translate evidence into measurable improvement ................................................................................................................... 10 Base policies and action on the nature of the care setting ..................................................................................................... 10 Use both scientific expertise and patient experience to improve ....................................................................................... 10 4. Partners in Action ........................................................................................................................................................................................... 11 5. Framework for Action.................................................................................................................................................................................... 15 Strategic Objective 1: Policies to eliminate avoidable harm in health care ...................................................................... 16 Strategic Objective 2: High reliability systems ........................................................................................................................... 21 Strategic Objective 3: Safety of clinical processes ..................................................................................................................... 28 Strategic Objective 4: Patient and family engagement .......................................................................................................... 35 Strategic Objective 5: Health worker education, skills and safety ....................................................................................... 41 Strategic Objective 6: Information, research, risk management and improvement ..................................................... 47 Strategic Objective 7: Synergies, partnerships and solidarity ............................................................................................... 55 6. Implementation .............................................................................................................................................................................................. 59 7. Global Patient Safety Targets ...................................................................................................................................................................... 63 8. Alignment of Patient Safety with the Sustainable Development Goals (SDGs) ....................................................................... 65 9. Mapping of WHA Resolution (WHA72.6) to the Global Patient Safety Action Plan ............................................................... 69 10. Bibliography ..................................................................................................................................................................................................... 74 Table of Contents | iii Overview of the Global Patient Safety Action Plan 2021–2030 Vision A world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere Governments Stakeholders Health care facilities WHO Secretariat Mission Drive forward policies and actions, based on science, system design and partnerships, to eliminate all sources of avoidable risk and harm to patients and health workers Goal Achieve the maximum possible reduction in avoidable harm due to unsafe health care globally Patients and families as partners Evidence into improvement Results through collaboration Policies and action Data to generate learning Scientific expertise and patient experience High-reliability Patient and family Information, research systems engagementt and risk management Policies Safety Health to eliminate of worker Synergies, avoidable clinical education, skills partnerships harm processes and safety and solidarity 1 Vision, mission and goal 6 Guiding principles 4 Partners in action 7 Strategic objectives Overview of the Global Patient Safety Action Plan 2021–2030 | v Abbreviations AHRQ : Agency for Healthcare Research and Quality GPSAP : Global Patient Safety Action Plan 2021 – 2030 ILO : International Labour Organization LMICs : Low- and middle-income countries NGOs : Non-governmental organizations OECD : Organisation for Economic Co-operation and Development SDGs : Sustainable Development Goals UHC : Universal health coverage UK : United Kingdom of Great Britain and Northern Ireland (the) UN : United Nations UNICEF : United Nations Children’s Fund VTE : Venous thromboembolism WASH : Water, Sanitation and Hygiene WHA : World Health Assembly WHO : World Health Organization Abbreviations | vii 1. Introduction ver the next 10 years, the World Health Organization It will be the driver, through its year-by-year milestones, O(WHO), its global partners and its Member States will for successfully implementing the Global Patient Safety be working tirelessly to help all people of the world to Action Plan. have access to health services. The Global Patient Safety Action Plan, set out in this Universal Health Coverage (UHC) is an inspiring goal that document, will provide a strategic direction for concrete aims, over the next five years, to see one billion more people actions to be taken by countries, partner organizations, having access to the safe and quality health services they care facilities and WHO to implement WHA resolution need without facing financial hardship. That is the target (WHA72.6). As a result, it will strengthen health systems that must be achieved if the world is to get on track and globally to diagnose, treat, cure, and care whilst striving stay on track to meet the Sustainable Development Goals to: “First do no harm,” the celebrated maxim of the Greek (SDGs). The sustainable development agenda will not be physician, Hippocrates (460–375 BC). met without ensuring that health services are safe. It will not be worth achieving if health care itself poses a threat to people’s health. The benefit of increased coverage would Background not be fully realized, and people could lose trust in health Every point in the process of care can contain an inherent services. This, in turn, would reduce their confidence to risk. Its nature and scale vary greatly based on the context seek health care even when they most needed it. of health care provision and its availability, infrastructure That is why the World Health Assembly (WHA) in May and resourcing within and across countries. The challenge 2019 adopted a resolution ‘Global action on patient safety’ for all health systems, and all organizations