Patient Safety Representatives Unite to Implement Global Patient Safety Action Plan in the United States

Preventable harm in the healthcare system is an urgent public health challenge, internationally and in the United States.  Globally, more people die now from medical errors or other breakdowns in the quality and safety of healthcare services than from lack of access to them. ⁽¹⁾ Researchers estimate that medication errors, preventable infections, venous thromboembolism, falls, and other preventable harms in hospitals take the lives of 400,000 or more Americans annually. ⁽²⁾⁽³⁾

That’s where we come in. We are the founders of the United States branch of Patients for Patient Safety (PFPS US), an international network of patient and family representatives established by the World Health Organization (WHO) in 2004. We are individuals who have experienced medical error as a patient or in our families. Our mission is to make effective change in the United States by actively supporting the implementation of the new WHO Global Patient Safety Action Plan 2021-2030 in our country. Canada and other nations have established and grown their own branches. PFPS US now follows their lead and our network of patient safety representatives and our partners are dedicated to ensuring safe healthcare is available to all. PFPS US is led by Sue Sheridan and co-founders are Margo Burrows, Steve Burrows, Lt. Col. Steven L. Coffee, Alicia Cole, Martin J. Hatlie, Carole Hemmelgarn, Soojin Jun, Armando Nahum and Beth Daley Ullem.

As engaged patient safety representatives, we see too little progress in meeting the goals set forth 20 years ago in the U.S. Institute of Medicine’s 1999 call to action, To Err is Human [PDF – 10 pages], which called for a 90% reduction in medical errors in 10 years.  While we are thankful for the continued focus and success in preventing healthcare-associated infections in healthcare settings in the United States, there is more work to be done. Medical errors now vie with COVID-19 infections as the third largest cause of preventable death in the United States. ⁽⁴⁾  There is a critical need for patient safety solutions to be embedded across both public and private healthcare sectors. We must prioritize this problem that impacts so many families like ours.

In 2019 the World Health Assembly established September 17 as World Patient Safety Day and passed a resolution calling on every nation to implement specific strategies shown to reduce harm and death from medical error. In May 2021, the WHO Global Patient Safety Action Plan 2021-2030 was adopted, outlining seven strategic objectives and calling upon governments, healthcare leaders, patients and families, and other stakeholders to work together to achieve them. The objectives include:

• Develop government policies to eliminate avoidable harm in health care
• Embed high-reliability safety systems in healthcare organizations that protect both patients and the healthcare workforce
• Ensure adoption of and accountability for following safe clinical processes
• Engage patient and family members as partners in co-producing policies and solutions
• Invest in health worker education and skills building that prioritize patient safety
• Advance continued innovation in information use, research and risk management
• Work together synergistically in partnership and solidarity towards reducing all preventable harm in healthcare

PFPS US is dedicated to advancing these objectives in the United States, and we welcome other patients and family members, government agencies, healthcare organizations and other stakeholder organizations to join us as partners going forward. Visit the PFPS US website for more information.

References:

1. Kruk ME et al, Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries, The Lancet, 2018; 392: 10160, pp 2203-2212-2236. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31668-4/fulltext. Accessed September 24, 2021.
2. Makary MA, Daniel M. Medical error-the third leading cause of death in the US.BMJ. 2016;353:i2139. Available at: http://www.bmj.com/content/353/bmj.i2139. Accessed September 24, 2021.
3. James JT., A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care, J Patient Saf. 2013;9:122–128. Available at: http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/.
4. Makary, Medical Error-the third leading cause of death.

Armando and his wife, Victoria, began their work in patient safety and engagement after three members of their family developed infections in three different hospitals, in three different states in 10 months’ time, culminating with the death of their son, Josh. He was just 27. Armando’s patient safety work has been featured on national and local television and radio programs, including the CBS Evening News with Katie Couric, FOX News, CNN: The Situation Room with Wolf Blitzer and The Dr. Oz Show, as well as in numerous articles in journals and publications including Infection Control Today and CNN’s The Empowered Patient, The Wall Street Journal, The Washington Post, and The New York Times.