Sir Liam Donaldson, Chair of the WHO World Alliance for Patient Safety and Chief Medical Officer for England, opened the symposium with a presentation that focused on the assertion that patient safety could be greatly improved. Sir Liam highlighted the importance of putting patient safety first and that the health sector could learn a lot from the experience of other high-risk industries such as the aviation or nuclear industries.
The airline industry, for example, has greatly improved safety by not merely dealing with individual (pilot) mistakes, but by concentrating on failures in the overall system. This requires a broad approach that includes transforming the culture, attitude, leadership and working practices of everybody involved in the industry. It also involves a much more systematic monitoring and constant training of the professionals active in the sector. In this respect he favorably compared the constant checking and training of pilots with the existing situation in the health care system. According to Sir Liam, the health sector, by following the approach of the airline industry, could greatly improve patient safety and significantly reduce the risk to patients.
However, even in countries that have sought to address this issue for years, progress is slow and further systematic efforts need to be made. Another issue concerns the balancing of patient safety against financial objectives and the regrettable lack of public accountability of health care professionals when patient safety issues are concerned.
Subsequently, Ms. Suzan E. Sheridan, of the Patient Safety, Consumers Advancing Patient Safety, Chicago, USA, spoke about the role of local community involvement in improving patient safety. Ms Sheridan's involvement in this topic comes from her own family's dramatic experience with two serious medical system failures. Such failures can often be prevented by assuring that health care consumers and their care takers are actively involved in treatments, i.e. patients should not have to solely rely on health professionals. Ms. Sheridan challenged health care providers, institutions, organizations and agencies to recognize and embrace the value and power of partnerships in reshaping the future of healthcare so that it is safe, compassionate and just. In this context Ms Sheridan gave a poignant example of health services consumers' involvement, P.I.C.K. (parents of infants and children with Kernicterus). This initiative started some years with only eight Moms and is now a national campaign.
The last speaker was Mr. S. Whittaker of the Council for Health Service Accreditation of Southern Africa (Cohsasa) who spoke from the perspective of developing countries. Mr. Whittaker recognized the reality in many African countries patients are at risk as they have to deal with violence in hospitals, outdated x-ray machines, questionable hygienic standards, etc. It is a paradox that although staff is often serious, patients are still frequently put at risk
Cohsasa seeks to improve the situation by implementing its Wedge Model. The Wedge Model has a double approach. On the one hand, it implements a standard quality improvement program that aims at improving facility, clinical, management, clinical and non-clinical support and technical systems. Although there is good support for this in the hospitals, Cohsasa finds that in the provinces, where one has to deal often with demoralized staff, progress is difficult. On the other hand, Cohsasa monitors adverse events that aim at identifying and improving systems failures that impact on patient safety, while they are being improved by the standard improvement arm.
This two-pronged approach permits serious system failures to be identified and interventions prioritized to ensure that patient safety is maximized.
