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World Alliance for Patient Safety – Forward Programme 2006-2007

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WHO. World Health Organization. World Alliance for Patient Safety. Forward Programme 2006-2007. Geneva: WHO Press; 2006.

Health care which is as safe as possible, as soon as possible — this is the simple, yet powerful mandate given to the World Alliance for Patient Safety by patients around the world.

In its simplicity lies a significant challenge for all health-care systems. Globally, action on patient safety is gaining momentum.

Health-care policy-makers around the world are making patient safety a priority. Work on the Alliance’s international action areas is gaining pace.

However, the case for even greater action is compelling and urgent. Errors in health care know no geographical boundaries. No country — rich or poor — can claim to have fully come to grips with the problem of patient safety.

Improving patient safety requires carefully designed systems of care which reduce risks to patients. Complementary actions are needed to prevent adverse events, make them quickly visible when they do occur, mitigate their effects on patients and health-care workers and reduce risks to future patients. Change is needed at the level of individual health-care workers, teams, organizations and whole health-care systems. Competent, conscientious and safety-conscious health workers in frontline services are vital.

As the Alliance has undertaken work throughout the world, a series of common challenges have emerged.

First: the need to raise awareness of the size of the patient safety problem and build political commitment to action. Patient safety is a big and serious problem and risk is an inherent feature of many aspects of health care. Without strong and committed leadership the patient safety movement cannot succeed.

Second: solving safety problems for which we already have ample information about causes and solutions. It is striking that the same errors and system failures are repeated not only across but also within countries. Action to address known risks is often too slow and poorly implemented.

Third: the problem of timely identification of new issues and their solutions. Despite increased effort, our systems to detect risk and patient safety problems are still primitive. Even when adverse events do occur, many of them are not reported by health-care workers. A culture of blame — rather than a culture of learning — is alive and well. Blame and retribution cause harm and prevent safety flourishing.

Inadequate systems for detecting problems mean that our understanding of the causes of patient safety problems is incomplete. This is the knowledge we must have if we are to design effective solutions. Knowledge is the enemy of unsafe care.

Fourth: developing open partnerships with patients. Health-care organizations are typically defensive in dealing with patients and their carers in the aftermath of a serious event. Patients and their carers are rarely asked for feedback on risks and problems. The wisdom of patients is not effectively harnessed.

This Forward Programme 2006-2007 sets out an ambitious and comprehensive agenda for action on patient safety. Everyone working in health care needs to play their part. The stakes could not be higher. Safe care is not an option. It is the right of every patient who entrusts their care to our health-care systems.

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