Patient Safety Summit
Patient Safety: A Global Agenda
Secretary of State Patricia Hewitt, Sir Liam, Colleagues, Ladies and gentlemen,
Each time a patient is harmed by the health system, it is a betrayal of trust. These so-called "adverse events" are actually "reverse events". Instead of advancing people's health and well-being, medical errors send them backwards, causing more harm than good.
The story of those injured through adverse events is a story of individuals. Similarly, there is an individual whose drive has put patient safety firmly on the health agenda all around the world - Sir Liam Donaldson. I know his chairmanship of the World Alliance will continue to be an important element of the success of the patient safety programme in WHO. Thank you, Liam, for your commitment and passion.
You have announced, Madam Secretary of State, the intention of the UK to formalize its partnership with the WHO Patient Safety programme and the work of the World Alliance for Patient Safety. This is good news, and I thank you for this commitment.
But, ladies and gentlemen, at this moment, somewhere, somehow, someone is dying because of one of these "adverse" events.
This someone has a face: they are a son, a daughter, a grandchild, a parent.
"Adverse event" is a euphemism. It does what euphemisms do: it protects us from the stark reality and pain of confronting what that event actually means. Perhaps it has also protected us from taking full responsibility for the consequences of those events.
So let's face the facts. Those patients, or their guardians, family, or friends have trust and confidence in the health system and modern medicine. They may have had to walk, or be carried long distances through difficult terrain to get treatment. That "someone", who is sick or injured, is desperate for help to save his or her life. Yet in developing countries, more than half of the medical equipment in use is faulty. Often, correct diagnoses are not made. Anesthesia can be incorrectly administered. Even in developed countries, one in ten patients is seriously harmed by the hospital care that should be saving them.
Behind such figures can lie struggling health systems. Many countries face critical gaps in infrastructure, medical technologies, and human resources for health. Investment in health systems remains inadequate. This is a priority area for public health action, which will have an impact on patient safety.
An increasing body of research knowledge and experience internationally shows that interventions which are designed to heal patients can also harm them. The health care institutions and providers are not infallible. For a long time the extent of the problem was not articulated. These facts can no longer be ignored. The causes of unsafe care must be stringently reviewed and energy and resources put into addressing them. Behind the statistics lie the stories of people around the world whose lives are devastated by the consequences of unsafe care.
The facts are deeply shocking. The individual stories reiterate the waste of life. In Mexico City, Uriel suffered permanent brain damage at birth because of medical mistakes made in the delivery process. In the UK, 54-year-old Alan was permanently disabled by the unnecessary removal of part of his oesophagus, after it was wrongly biopsied and cancer incorrectly diagnosed. In the USA, 18 month old toddler Josie died when a pain killer was wrongly prescribed and administered.
Every adverse event is unique in its way. But looking closely, we see a common link. Each event tells a story. Together there is an encyclopedia of lessons. Those lessons must be rigorously applied.
There is another dimension to our responsibility as providers of health care. This dimension is the cost of such care, and what it means to a poor family to pay for medical attention - that may then be lethal. The cost of that care may send the family deep into debt. The responsibility for providing value for money is perhaps greatest of all where resources are most scarce. Yet it is in those settings that lack of servicing for equipment, or lack of appropriate medicines may be most likely. The loss or disability of an income earner is catastrophic. No society can afford these losses - and struggling economies least of all.
For the past year, the Alliance has been delivering a demanding agenda to ensure that all patients' right to safer and equitable care is met. You have my support in this. I welcome the Alliance's efforts to increase international collaboration in this field; to support the agreed research agenda; and to promote existing patient safety interventions. The progress already made is an encouraging illustration of how care can be made safer around the world. But there is much more to be done. National governments can make a big difference by integrating patient safety as a core aspect of their public health programmes. The commitment and energy of all of you gathered here at this Summit is needed to accomplish our goals.