1、2024Global patient safety report 2024lobpPatient Safety Flagship UnitIntegrated Health Services Department World Health Organization20,Avenue Appia1211 Geneva 27SwitzerlandEmail:patientsafetywho.intWebsite:https:/www.who.int/health-topics/patient-safetyGlobal patient safety report 2024Global patient

2、 safety report 2024 ISBN 978-92-4-009545-8(electronic version)ISBN 978-92-4-009546-5(print version)World Health Organization 2024Some rights reserved.This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0IGO licence(CCBY-NC-SA3.0IGO;https:/creativecommons.org/lice

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12、ed without warranty of any kind,either expressed or implied.The responsibility for the interpretation and use of the material lies with the reader.In no event shall WHO be liable for damages arising from its use.Design:Macro Graphics Pvt.Ltd.|iii|ContentsForeword Dr Tedros Adhanom Ghebreyesus viiFor

13、eword Sir Liam Donaldson viiiForeword Dr Bruce Aylward xPreface Dr Neelam Dhingra xiiPreface Dr Rudi Eggers xivAcknowledgements xvAbbreviations xixGlossary of terms xxiExecutive summary xxviiIntroduction 1Burden of harm in health care 11Burden of harm to the patients 14Geographic distribution of har

14、m in health care 14Burden of harm by demographic distribution 15Burden of harm by medical setting and clinical domain 17Burden of harm by source 21Measurement considerations and conclusions 25Financial and economic burden of unsafe care 27The direct costs unsafe care imposes on health care systems a

15、nd budgets 28Direct costs by setting and source of harm 29Indirect costs of unsafe care 31Strategic objective 1.Policies to eliminate avoidable harm in health care 35Strategy 1.1.Patient safety policy,strategy and implementation framework 41Patient safety as a priority in national health policy 41In

16、tegration of patient safety in UHC service delivery packages 43Patient safety policy and strategy 44National patient safety action plan 45National patient safety programme 45Strategy 1.2.Resource mobilization and allocation 50Budget category and allocation of financial resources 50Human resource pla

17、n and gap closure 51Recognition and reward mechanisms 52Strategy 1.3.Protective legislative measures 54Mandatory licensing for health care facilities and services 54Laws for authorization of medical products 55Legal protection against reporting of patient safety incidents 56Data protection and confi

18、dentiality 57|iv|Global patient safety report 2024 WHO/Martha TadesseStrategy 1.4.Safety standards,regulation and accreditation 61Minimum safety standards 61Safety standards in health care licensing 62Safety standards for all specified clinical services 63Safety standards in health services assessme

19、nt tools 64Voluntary accreditation programmes and safety standards 65Strategy 1.5.World Patient Safety Day and Global Patient Safety Challenges 67World Patient Safety Day 67WHO Global Patient Safety Challenges 70Strategic objective 2.High-reliability systems 75Strategy 2.1.Transparency,openness and

20、no blame culture 82Safety culture implementation 83Never and/or sentinel events reporting 84No blame policy and just culture 85Strategy 2.2.Good governance for the health care system 89Institutional framework for patient safety 89National focal point for patient safety 90Strategy 2.3.Leadership capa

21、city for clinical and managerial functions 93Country examples of advancing patient safety leadership capacity 94Strategy 2.4.Human factors/ergonomics for health systems resilience 96Applying human factors for improving patient safety 96Structural and non-structural safety of health care infrastructu

22、re 98Strategy 2.5.Patient safety in emergencies and settings of extreme adversity 100Patient safety integration in health emergency preparedness,response and recovery plans 101Risk management for patient safety 101Strategic objective 3.Safety of clinical processes 105Strategy 3.1.Safety of risk-pron

23、e clinical procedures 111Identifying sources of significant patient harm 112Patient safety improvement initiatives to address major sources of harm 112Patient safety improvement initiatives in clinical disciplines 114Strategy 3.2.Global Patient Safety Challenge:Medication Without Harm 120Implementat

24、ion of the third Global Patient Safety Challenge:Medication Without Harm at the national level 122Key action areas for medication safety 123Patient education about medicines 124Safety initiatives for traditional and complementary medicines 126Mechanisms of reporting and measuring adverse drug events

25、 and medication-related harm 128Strategy 3.3.Infection prevention and control&antimicrobial resistance 132National infection prevention and control programmes 133Infection prevention and control guideline implementation and monitoring 133Infection prevention and control education and training 134Hea

26、lth care-associated infection surveillance 135Strategy 3.4.Safety of medical devices,medicines,blood and vaccines 138Safety regulations for medicines and medical products 139Programmes for safety of medicines 140Programmes for safety of blood and blood products 141Programmes for safety in immunizati

27、on services 142Programmes for safety of medical devices 143|v|Strategy 3.5.Patient safety in primary care and transitions of care 144Transitions of care and clinical pathways for primary care 145Certification and accreditation programmes for primary care services 146Implementing patient safety syste

28、ms interventions in primary care 148Patient safety in mental health services 149Strategic objective 4.Patient and family engagement 155Strategy 4.1.Co-development of policies and programmes with patients 162Patient engagement in policies,programmes,and governance 162Identification of patient organiz

29、ations 163Patient engagement as an assessment criterion for health care facilities 164Patient safety rights charter 164Strategy 4.2.Learning from patient experience for safety improvement 167Patient feedback mechanisms 167Learning from patients stories 168Strategy 4.3.Patient advocates and patient s

30、afety champions 171Recognition and capacity building of patient advocates and champions 173Patients for Patient Safety networks 173Strategy 4.4.Patient safety incident disclosure to victims 177Guidance for obtaining informed consent 177Patient access to medical records 178Disclosure of adverse event

31、s to patients and families 179Psychological support in case of adverse events 180Strategy 4.5.Information and education to patients and families 182Health literacy and patient engagement 182Information about safety and quality of health services 183Use of digital technologies 184Strategic objective

32、5.Health worker education,skills and safety 187Strategy 5.1.Patient safety in professional education and training 194Adoption of WHO Patient Safety Curriculum Guide 195Patient safety in undergraduate and postgraduate curricula 196In-service training on patient safety and health worker safety 198Stra

33、tegy 5.2.Centres of excellence for patient safety education and training 200Patient safety institutions and training centres 200Innovative teaching methods and simulation 201Strategy 5.3.Patient safety competencies as regulatory requirements 203Establishment of patient safety core competencies 203Pa

34、tient safety core competencies as a regulatory requirement 205Authorization for working in high-risk clinical areas 206Strategy 5.4.Linking patient safety with appraisal system of health workers 208Performance appraisal systems for health workers 208Performance linked reward and recognition programm

35、es 209Strategy 5.5.Safe working environment for health workers 211Endorsement of WHO Health worker safety charter 212National occupational health programmes for health workers 213Mental health services for health and care workers 214Vaccination programmes for health workers 215Protection for violenc

36、e against health and care workers 216|vi|Global patient safety report 2024 Strategic objective 6.Information,research and risk management 221Strategy 6.1.Patient safety incident reporting and learning systems 227Patient safety incidents classification and reporting format 228Functional patient safet

37、y incident reporting and learning systems 230Paper versus electronic reporting 232Voluntary versus mandatory reporting 232Types of incidents reported 233Safety alerts based on learning from incidents 235Strategy 6.2.Patient safety information systems 241Identification and mainstreaming of patient sa

38、fety indicators 242Monitoring of patient safety indicators 244Annual reporting on patient safety 245Strategy 6.3.Patient safety surveillance systems 249Sources of patient safety information 249Investigation mechanisms in cases of serious harm 252Strategy 6.4.Patient safety research programmes 257Ide

39、ntification of research priorities for patient safety 257Safety risk assessment integration with health technology assessment 259Strategy 6.5.Digital technology for patient safety 260Use of digital technologies for improving access and safety 260Electronic health records 261Patient safety in digital

40、 health 262Strategic objective 7.Synergy,partnership and solidarity 265Strategy 7.1.Stakeholder engagement 272Stakeholder mapping and analysis 273Stakeholder coordination mechanism 273Strategy 7.2.Common understanding and shared commitment 278Aligning national patient safety initiatives with global

41、action plan 278Shared commitment for patient safety-Global collaborative landscape 279WHO engagement with stakeholders 281Strategy 7.3.Patient safety networks and collaboration 283Stakeholder consultations for implementing patient safety action plans 283National Patient safety networks 284Collaborat

42、ive alliance for promoting patient safety 286Strategy 7.4.Cross-geographical and multisectoral initiatives for patient safety 289Global Ministerial Summits on Patient Safety 290Dissemination of innovative ideas and best practices 291Strategy 7.5.Alignment with technical programmes and initiatives 29

43、4Integration of patient safety programmes 295References 297Annexes 315Annex 1.Core indicators Global patient safety action plan 20212030 317 Annex 2.Framework for action:The 7x5 matrix 318 Annex 3.Patient safety regional profiles 319|vii|ForewordPatient safety is one of the most ancient and fundamen

44、tal principles of medicine,and an essential part of every countrys journey towards universal health coverage,and the other health targets in the Sustainable Development Goals.And yet,nearly one in ten patients is harmed in health care,translating into over three million deaths globally each year.Mor

45、e than half of this harm is preventable.This shocking statistic must serve as a call to action for systemic change.The Global patient safety action plan 20212030,adopted by the World Health Assembly in 2021,is a testament to the collective resolve of WHO Member States to confront this challenge.The

46、action plan aims to eliminate avoidable harm in health care and empower patients and their families to demand and receive safer care.Developed with the insight and dedication of safety experts,patient advocates and millions of health workers worldwide,the action plan is a blueprint for building more

47、 resilient health systems that are safe and adaptable in the face of emergencies.In 2023,World Patient Safety Day emphasized the critical role of patients and families in shaping health care.From informed consent and shared decision-making at the point of care to their involvement in policy-making a

48、nd governance,their voices are indispensable.However,this report shows nearly half of the countries surveyed have yet to take meaningful steps to involve patient representatives in health care governance.This inaugural Global patient safety report sheds light on the commendable progress made by many

49、 countries,but also underscores the vast scope for further improvement.While patient safety has gained recognition in national health policies,translation into strategic action and tangible implementation solutions lags,due to resource constraints and inadequate execution of patient safety policies

50、and programmes.This report captures progress made and charts the course forward,offering a comprehensive strategy to promote patient safety through the systemic changes outlined in the global action plan.This kind of change doesnt just happen;it requires strong political commitment and concerted eff

51、ort at national and local levels.I hope this report serves as a call to action to political leaders and policy-makers,health service providers,advocates and especially patients and their families to unite for safer care.Because if its not safe,its not care.ForewordDr Tedros Adhanom GhebreyesusWHO Di

52、rector-General|viii|Global patient safety report 2024 Almost 25 years have passed since two seminal reports captured public and professional attention on the little-recognised subject of unsafe care.In 1999,the Institute of Medicine in the United States published To err is human and,in parallel,in t

53、he United Kingdom in 2000,An organisation with a memory set out a way forward for the countrys National Health Service.Until then,the adverse effects of medical care were largely seen through the lens of medical negligence.When something went wrong,the first call would be to a lawyer.Instead,both re

54、ports implied that,in future,viewing the harmful outcome and the events that led to it through the lens of accident causation was more likely to save lives.In turn,although it would have seemed fanciful at the time,perhaps the first call should be to human factors experts,rather than lawyers.Althoug

55、h this turn-of-the 21st century-thinking was recognising a new paradigm for avoidable harm in health care a focus on systems and their vulnerabilities rather than individual error it took time to unfold in health systems around the world.An initiative,led and funded by the United Kingdom,formed the

56、World Alliance for Patient Safety,a group of experts and leaders that forged a partnership with WHO to drive forward action on patient safety at global level.Crucially,the World Alliance reached out to,and fully engaged with,safety experts from other high-risk industries.An initial programme of work

57、 included:the first Global Patient Safety Challenge(Clean care is safer care),a patient safety research programme,and a programme led by patients and families who had suffered harm(the Patients for Patient Safety Programme).After laying the foundations for an organised approach to preventing harm in

58、 health care,and providing a crucial initial period of innovative global leadership,the work of the World Alliance for Patient Safety was absorbed within WHOs management structure in the late 2000s.The World Alliances work has stood the test of time with much of it being carried forward in the patie

59、nt safety programmes that followed.Certain key advances have marked the patient safety journey during the 21st century,including:1.Greater awareness that the scale of avoidable harm from unsafe care ranks highly in global burden of disease terms.ForewordSir Liam DonaldsonWHO Director-General Special

60、 Envoy for Patient Safety|ix|Foreword2.Regular and widespread commitments by policy-makers,health leaders and professional bodies that patient safety should be a priority of health systems and in all places where health care is delivered.3.A clear understanding of why and how care becomes unsafe,inc

61、luding the importance of systems thinking and the human factors perspective.4.The establishment of patient safety incident reporting and learning systems in many places.5.A recognition that patient and family engagement and involvement is essential to the planning,design and delivery of safe health

62、care.6.The growth,and greater funding,of research studies of patient safety.While there has been advancement in each of these areas,it has been slow and very uneven.For example,while many health systems and health facilities have accorded a high priority to patient safety in their strategic and busi

63、ness plans,a smaller proportion have been able to integrate necessary actions to reduce risk and prevent harm within their day-to-day operations.Similarly,not all professional staff have made patient safety foundational to their practice.Moving patient safety from the territory of enthusiasts and ac

64、ademics to the mainstream has been a slow and faltering process.It is not there yet.It must remain a fundamental and transformational aim of patient safety programmes everywhere.Moreover,whilst the experience of patients and families have been shaping actions to improve the safety of care at global,

65、national and health facility levels,this is also patchy.There are still too many examples around the world of patients and their families not being listened to when they have valid concerns about the safety of care being provided.Victims of harm often have to fight to uncover the truth of what happe

66、ned.In some jurisdictions,the opportunity to learn from patient safety incident reports is being lost because of organisational cultures characterised by fear,blame and retribution for those who make errors.The ground-breaking,first Global patient safety action plan 20212030 was adopted by the 74th

67、World Health Assembly in 2021.It took stock of the progress that has been made but noted the low impact on avoidable harm relative to the effort and money put into trying to reduce such harm,and keep patients safer.It set out seven core objectives with truly transformative potential and commended th

68、em to all WHO Member States,to every health system and to each and every health care facility and health service around the world.Across all the dimensions of patient safety in the last quarter century,the greatest difficulty has been in achieving successful implementation of action to reduce harm t

69、o patients.There is great diversity in the structure,funding and governance of health care around the world.There are also many different designs of health care systems and great variation in the way that health care facilities are led and managed.Settings where care is delivered are very diverse to

70、o.The implementation of the Global patient safety action plan 20212030 leaves room for flexibility of approach,taking account of existing organisational context and resource deployment options.It is essential,though,to ensure that there is absolutely no departure from the determination to deliver th

71、e core objectives and supporting actions of the plan.This Global patient safety report aims to assess the early phase of delivery of the action called for in the Global patient safety action plan 20212030.It will serve as a baseline for judging future progress,and as a source of learning and improve

72、ment.It will be a stimulus and inspiration for the ultimate commitment that must be made to patients and families:showing them that health services around the world can protect them from harm on every step of their care journey,every time they make one.|x|Global patient safety report 2024 The import

73、ance of patient safety as a key component of all health care has been globally and increasingly recognised over the past decade with strong national and international commitments to advance the provision of safe care.Every year millions of people are harmed and suffer disability or death as a result

74、 of unsafe health care.People in low-and middle-income countries(LMICs)are disproportionately affected,with an estimated 134 million adverse events contributing to 2.6 million deaths each year in LMICs.In the last five years,there have been significant developments in patient safety.Advocacy by dive

75、rse stakeholders and groups has culminated in the adoption of Resolution 72.6,Global action on patient safety,at the seventy-second World Health Assembly(2019).The decision of the seventy-fourth World Health Assembly to adopt the Global Patient Safety Action Plan 2021-2030 marked a new phase in impl

76、ementing patient safety.As a result,Member States are increasingly recognising patient safety as a policy priority,and committing to work towards zero harm in health care.However,there is still much work to be done,to ensure safe and high-quality care is a key component of building better systems to

77、 provide universal health coverage and ensure better health outcomes.This landmark global patient safety report highlights both the work already done to implement the recommendations of the Plan and reduce harm,and the considerable distance that remains to ensure safe care for all.It serves as a sta

78、rting point to track and report progress to 2030 against the seven strategic objectives of the Plan,as adopted by the World Health Assembly.WHOs new global patient safety reporting and monitoring system,to which 108 countries responded,forms the basis of this report and is essential to enable regula

79、r tracking of progress over time,to celebrate achievements and identify gaps,while providing a common foundation for national reports on patient safety.Sustainable political commitment and investment is essential to advance the patient safety agenda.This report finds that while 55%of countries recog

80、nise patient safety as a key priority in their national health policy,safety incidents still cost health systems billions of dollars each year.Investments in safety are cost-effective and crucial in an era of significant demands on resources.ForewordDr Bruce AylwardAssistant Director-GeneralUniversa

81、l Health Coverage,Life CourseWorld Health Organization|xi|ForewordAs part of investing in patient safety,ensuring the safety of health workers is crucial.The COVID-19 pandemic demonstrated how the health and well-being of health workers is inextricably connected to the safety of patients.We must do

82、more to protect health workers.Importantly,this report finds that almost 70%of countries have established or are working towards establishing a national programme for occupational health and safety of health workers.This report provides a benchmark for future improvements and aims to accelerate acti

83、on on patient safety in all Member States.As implementation of the Global Patient Safety Action Plan advances,we must continue our endeavour to learn more,working with health workers,patients and families,and our partners,expanding research capacities,increasing improvement efforts,and embedding a s

84、afety culture in health systems.WHO remains fully committed to delivering the health-related Sustainable Development Goals and collaborating with all stakeholders to ensure that patients around the world receive safe and high-quality care.|xii|Global patient safety report 2024 The paramount goal of

85、modern medicine is to ensure that treatments benefit patients without causing harm.However,as we delve into the intricacies of health care systems worldwide,it is clear that achieving this ideal consistently is a significant challenge.The issue of patient harm casts a long shadow,presenting not mere

86、ly as sporadic errors but also as pervasive problems requiring urgent and substantial change.As the field of medicine progresses,emphasizing patient safety and reducing preventable risks becomes essential to protect the health and well-being of those we serve.Whenever we ask How big is the problem?,

87、we find estimates based on studies mainly from high-income countries.The data from low-and middle-income countries are still scarce.It is reasonable to say that the actual burden of patient harm in health care is grossly underestimated or actually unquantifiable,because it cannot take into account t

88、he human suffering and devastation it causes in peoples lives.And the impacts of such harm which is both unnecessary and easily preventable are disproportionately severe compared to the original error or unsafe practice.As a medical student,I can recall incidents of harm that were regarded as normal

89、 consequences of treatment,such as a patient having jaundice after blood transfusion.Back then,harm in health care was normalized.In the interim,there have been years of extensive efforts to improve patient safety globally,spearheaded by the strategic and visionary leadership of global patient safet

90、y champions,influencers and political leaders.The global momentum created by the annual ministerial summits on patient safety since 2016 led to a landmark World Health Assembly resolution in 2019:Global action on patient safety identified patient safety as a global health priority and established Wo

91、rld Patient Safety Day.In response to this global call,WHO established a flagship initiative entitled A Decade of Patient Safety 20202030 to support strategic actions in patient safety at the global,regional and national levels.The WHO flagship initiative cuts across different areas of work within t

92、he organization,focusing on linkages between patient safety and health care safety components in the various health systems elements,and linkages with disease-specific and clinical programmes,which have direct impact on patient safety and health outcomes at the point of care.Given the complex challe

93、nges that health care systems face globally,two key questions arise:“Can we eliminate avoidable harm in health care?”and,if so,“How do we achieve it?”We need to put in place systems,protocols and procedures to reduce the risks of harm and,if harm occurs,reduce its impact.PrefaceDr Neelam Dhingra Uni

94、t Head Patient Safety Flagship UnitWorld Health Organization|xiii|PrefaceEffective action for improved patient safety relies on enhanced trust in health services,better patient experience and improved health outcomes.Only strong leadership,commitment for sustained efforts,and concerted actions at gl

95、obal,national,subnational,institutional and community levels can bring the global vision of patient safety to reality.As we move ahead,it is imperative that we keep patient safety at the forefront of health care policies and practices.This isnt just a professional obligation,it is a moral imperative

96、 to uphold the trust placed in us by those who seek our care.The discourse surrounding patient safety is not merely a technical area it is a narrative of human lives,of real suffering,and the indomitable spirit of survival.It is incumbent upon each one of us,from practitioners to policy-makers,to en

97、sure that this narrative bends towards safety,healing and hope.This Global patient safety report 2024 is an important first step to demonstrate incremental improvements in patient safety over a decade.I truly believe that the key messages emerging from this report will provide a huge impetus for cou

98、ntries and stakeholders to prioritize action and pave a way for transformative changes in the safety of health care.|xiv|Global patient safety report 2024 The World Health Organization presents this inaugural Global patient safety report as a key output of the Integrated Health Services Department.S

99、ince its inception,catalysed by the World Alliance for Patient Safety in the early 2000s,our department has been dedicated to enhancing the safety and quality of health care worldwide.This report encapsulates our journey and accomplishments and charts a path forward for integrating quality of care a

100、nd patient safety into the broader context of health system strengthening.Patient safety is an integral and key part of delivering quality health services at the point of care.It cuts across technical areas and various health system themes to assure integration,with touch points in service delivery,

101、health workforce,governance,and health informatics.This report reflects collective and continuous efforts to weave patient safety and quality of care into the fabric of health care delivery.It touches on the safety of traditional and complementary medicines,hospital physical safety,and the pivotal r

102、ole of health service assessment and information systems in enhancing patient safety.Collaboration has been a cornerstone of our shared success to date.Mirroring this joint commitment,the report has been enriched by contributions from various technical departments and units across WHO,illustrating t

103、he power of collective expertise and shared goals.However,there remains an urgent need to accelerate efforts to prioritize patient safety at the national level.Currently,only a fraction of countries has fully integrated patient safety into their health systems,indicating that,for many,it remains a w

104、ork in progress.As we present this report,we hope it will serve as a crucial reference point and inspire all stakeholders involved in health care to champion the cause of making health care safer and more resilient.The challenges are significant,yet the opportunities for improvement and innovation a

105、re vast.Together,we continue to strive for a world where patient safety is not optional,but a guarantee of quality health services.PrefaceDr Rudi EggersDirector Integrated Health Services DepartmentWorld Health Organization|xv|AcknowledgementsAcknowledgementsThe Global patient safety report 2024 has

106、 been produced by the Patient Safety Flagship Unit at the World Health Organization(WHO)headquarters,Geneva,under the supervision of Unit Head,Neelam Dhingra.The project was coordinated by Nikhil Prakash Gupta.Principal writing team from Patient Safety Flagship Unit,WHO headquartersNikhil Prakash Gu

107、pta,Neelam Dhingra,Irina Papieva.Key external contributors and reviewersAndrew Carson-Stevens,Cardiff University,United Kingdom of Great Britain and Northern Ireland;University of Manchester,United Kingdom-Maria Panagioti and Alexander Hodkinson;Niek Klazinga,Organisation for Economic Co-operation a

108、nd Development(OECD);Tim France,Luke Slawomirski,Nitya R.George and Minna Hakkinen-Wu(independent consultants).Contributors from Patient Safety Flagship Unit,WHO headquartersPriyadarshani Galappatthy,Maki Kajiwara,Alexandra Mary Shaw,Ayda Taha.Member State surveyThe Member State survey was coordinat

109、ed by Neelam Dhingra and Nikhil Prakash Gupta,WHO headquarters;Mondher Letaief,WHO Regional Office for the Eastern Mediterranean;Aparna Singh Shah,WHO Regional Office for South-East Asia;Nittita Prasopa-Plaizier and Ogusa Shibata,WHO Regional Office for the Western Pacific;Jons Gonseth Garca and Bla

110、nca Penaloza,WHO Regional Office for the Americas;Gertrude Avortri and Pierre Claver Kariyo,WHO Regional Office for Africa;Joo Joaquim Rodrigues Da Silva Breda and Mafaten Chaouali,WHO Regional Office for Europe.The Global patient safety assessment tool was developed by Nikhil Prakash Gupta,who,alon

111、g with Nitya R.George,conducted the data analysis of survey responses.The digital platform for survey in all six United Nations official languages was created by Maki Kajiwara and Laurent Constantin at WHO headquarters.Feature storiesThe development of feature stories was coordinated by Andrew Carso

112、n-Stevens and Sioned Gwyn,Cardiff University,United Kingdom with contributions from Maddy French,Lancaster University,United Kingdom and Sarah Yardley,University College London,United Kingdom.Individual case studies were contributed by Irungu Kamau,Ministry of Health,Nairobi,Kenya;Anabay Mamo,WHO Co

113、untry Office,Kenya;Hilde De Graeve,WHO Country Office,India and Irina Papieva,WHO headquarters(Feature story 1);Danish Patient Safety Authority,Copenhagen,Denmark-Lena Graversen and Torsten Breuerbach Larsen(Feature story 2);Patient Safety Flagship Unit,WHO headquarters-Ayda Taha and Neelam Dhingra(

114、Feature story 3);Singapore Health Services,Singapore-Tan Kok Hian,Zann Foo and Mabel Sim(Feature story 4);Saudi Patient|xvi|Global patient safety report 2024 Safety Center,Riyadh,Saudi Arabia-Yasser Alaska,Rabab Alkutbe,Mohammad Alwadei,Alia Albaharnah,Abdulelah Alhawsawi and Ali Asery(Feature story

115、 5);Clinical Systems and Services Unit-Nobhojit Roy and Monty Khajanchi(Feature story 6);Ministry of Health,Colombo,Sri Lanka-Nimali Wijegoonawardene,Dewani Ranaweera and Alan Ludowyke;Priyadarshani Galappatthy,University of Colombo,Sri Lanka(Feature story 7);Hardeep Singh,Veterans Affairs Medical C

116、enter and Baylor College of Medicine,Houston,United States of America(Feature story 8);Susan Sheridan,Patients for Patient Safety-US,Idaho,United States(Feature story 9)Healthcare Excellence,Ottawa,Canada-Ioana Popescu,Theresa Malloy-Miller and Linda Hughes(Feature story 10);Johns Hopkins University

117、 and Medicine,Baltimore,United States-Albert W.Wu,Melanie Curless,Sarah Fisseha and Bhakti Hansoti;JHPIEGO-Kelly Curran,Tigistu Adamu Ashengo,Amy Dear,Damtew W/Mariam Dagoye and Solomon Abebe Woldeamanuel(Feature story 11);Imperial College London,United Kingdom-Alexandra Shaw,Melanie Leis and Mike D

118、urkin(Feature story 12);Piyawan Limpanyalert,Healthcare Accreditation Institute,Nonthaburi,Thailand;Ronel Steinhobel,Ministry of Health,Quality Assurance Directorate,Pretoria,South Africa(Feature story 13);Peter Hibbert,Macquarie University,North Ryde,Australia(Feature story 14);National Office of Q

119、uality and Patient Safety,Health Service Executive,Dublin,Ireland-Marcella ODowd,Jennifer Martin,Orla Healy,Kilian McGrane,Emma Hogan,Grinne Cosgrove,Clona Murphy and Rob Brennan;Thrse McDonnell,University College Dublin,Ireland.(Feature story 15);Shaleel Kesavan,Department of Health and Social Care

120、,Leeds,United Kingdom;Ingo Hartel,Federal Ministry of Health,Berlin,Germany;and Neelam Dhingra,Patient Safety Flagship Unit,WHO headquarters(Feature story 16).Burden of harm in health careSection on Burden of harm to patients was written by Maria Panagioti and Alexander Hodkinson,University of Manch

121、ester,United Kingdom.Section on Financial and economic burden of unsafe care was written by Luke Slawomirski.Substantial contributions were made by Benedetta Allegranzi,Infection Prevention and Control Unit,WHO headquarters and Minna Hakkinen-Wu(independent consultant).WHO reviewersOnyema Ajuebor,He

122、alth Workforce Department,WHO headquarters;Benedetta Allegranzi,Infection Prevention and Control Unit,WHO headquarters;Eyob Zere Asbu,Economic Evaluation and Analysis Unit,WHO headquarters;Christine Sonja Autenrieth,Monitoring,Forecasting and Inequalities Unit,WHO headquarters;Gertrude Avortri,WHO R

123、egional Office for Africa;Sepideh Bagheri Nejad,Quality of Care Unit,WHO headquarters;Vinay Bothra,WHO Country Office,Timor-Leste;Mafaten Chaouali,WHO Regional Office for Europe;Sudipto Chatterjee,Mental Health Unit,WHO headquarters;Neerja Chowdhary,Mental Health Unit,WHO headquarters;Giorgio Comett

124、o,Health Workforce Department,WHO headquarters;Janet Diaz,Health Care Readiness WHE,WHO headquarters;Pradeep Dua,Traditional,Complementary and Integrative Medicine Unit,WHO headquarters;Rudi Eggers,Integrated Health Services Department,WHO headquarters;Erdenechimeg Enkhee,WHO Country Office,Mongolia

125、;John Fogarty,Clinical Services and Systems Unit,WHO headquarters;Ayako Fukushima,Pharmacovigilance Unit,WHO headquarters;Parminder Gautam,WHO Country Office,India;Katthyana Genevieve Aparicio Reyes,Quality of Care Unit,WHO headquarters;Jons Gonseth Garca,WHO Regional Office for the Americas;Dirk Ho

126、remans,Health Services Performance Assessment Unit,WHO headquarters;Elizabeth Iro,Chief Nursing Office,WHO headquarters;Ivan Ivanov,Occupational Health Unit,WHO headquarters;Pierre Claver Kariyo,WHO Regional Office for Africa;Sungchol Kim,Traditional,Complementary and Integrative Medicine Unit,WHO h

127、eadquarters;Shem Yator Kiptoon,WHO Country Office,Kenya;Marta Lado Castro-Rial,Health Care Readiness WHE,WHO headquarters;Mondher Letaief,WHO Regional Office for the Eastern Mediterranean;Blerta Maliqi,Quality of Care Unit,WHO headquarters;Margaret Montgomery,Water,Sanitation,Hygiene and Health,WHO

128、headquarters;Peter Mtundu Bischoff,Infection Prevention and Control Unit,WHO headquarters;Afifa Munawar,WHO Country Office,Pakistan;Shanthi Narayan Pal,Pharmacovigilance Unit,WHO headquarters;Matthew Neilson,Quality of Care Unit,WHO headquarters;Kathryn ONeill,Health Services Performance Assessment

129、Unit,WHO headquarters;Dorothy Amaleck Ngajilo,Occupational Health Unit,WHO headquarters;Edith Patouillard,Economic Evaluation and Analysis Unit,WHO headquarters;Nittita Prasopa-Plaizier,WHO Regional Office for the Western Pacific;Madhava Ram Balakrishnan,Pharmacovigilance Unit,WHO headquarters;Rober

130、to Reyes Landaverde,Chief Scientist and Science Division,WHO headquarters;Teri Reynolds,Clinical Services and Systems Unit,WHO headquarters;Valter Bruno Ribeiro|xvii|PrefaceFonseca,WHO Athens Office on Quality of Care and Patient Safety,Athens,Greece;Nadeeb Safiullah,WHO Country Office,Afghanistan;O

131、gusa Shibata,WHO Regional Office for the Western Pacific;Ali Shirazi,WHO Country Office,Pakistan;Aparna Singh Shah,WHO Regional Office for South-East Asia;Fumihito Takanashi,Pharmacovigilance Unit,WHO headquarters;Chelsea Maria Taylor,Health Services Performance Assessment Unit,WHO headquarters;Anth

132、ony Twyman,Infection Prevention and Control Unit,WHO headquarters;Kavitha Viswanathan,Health Services Performance Assessment Unit,WHO headquarters;Isabelle Wachsmuth,Patient Safety Flagship Unit,WHO headquarters;Lee Wallis,Clinical Services and Systems Unit,WHO headquarters;Jessica Chi Ying Ho Data

133、and Analytics Unit,Junping Yu,Blood and other Products of Human Origin Unit,WHO headquarters;Diana Zandi,Quality of Care Unit,WHO headquarters.External reviewers Michael A P Durkin,Imperial College London,United Kingdom;NorAishah Abu Bakar,Ministry of Health,Kuala Lumpur,Malaysia;Yolanda Agra,Minist

134、ry of Health,Social Services and EqualityMadrid,Spain;Rashid Al-Abri,WHO Collaborating Center for Quality and Patient Safety Training Muscat,Oman;Yasser Alaska,Saudi Patient Safety Center,Riyadh,Saudi Arabia;Abdulelah Alhawsawi,Saudi Patient Safety Center,Riyadh,Saudi Arabia;Huda Amer Al-katheeri,Mi

135、nistry of Public Health,Doha,Qatar;Martina Andricic,Federal Office of Public Health,Bern,Switzerland;Kari Annette Os,Directorate of Health,Oslo,Norway;Suninder S.Arora,Batra Hospital and Medical Research Centre,New Delhi,India;Ali Asery,Saudi Patient Safety Center,Riyadh,Saudi Arabia;Desalegne Bekel

136、e Taye,Ministry of Health,Addis Ababa,Ethiopia;Hannah Bettsworth,International Society on Thrombosis and Haemostasis(ISTH),Brussels,Belgium;Paul Bowie,International Ergonomics Association,Scotland,United Kingdom;Isabela Castro,The Beryl Institute,Rio de Janeiro,Brazil;Howard Catton,International Cou

137、ncil of Nurses(ICN),Geneva,Switzerland;Olfa Challouf,Ministry of health,Tunis,Tunisia;Meena Nathan Cherian,Geneva Foundation for Medical Education and Research,Geneva,Switzerland;Giulia Dagliana,Centre for Clinical Risk Management and Patient Safety,Florence,Italy;Katherine De Bienassis,OECD,Paris,F

138、rance;Ratna Devi,Patients for Patient Safety-Asia Pacific,Haryana,India;Maryanne DArpino,Healthcare Excellence Canada,Ottawa,Canada;Jean E.Courtney,Joint Commission International,Chicago,United States;Mohammed Elfatih,Police Hospital,Khartoum,Sudan;Renee F Wilson,Johns Hopkins Bloomberg School of Pu

139、blic Health,Baltimore,United States;Damian JJ Farnell,Cardiff University,United Kingdom;Sophie Feary,ISTH,London,United Kingdom;Frank Federico,independent patient safety expert,Massachusetts,United States;Aiden Fowler,Department of Health and Social Care,United Kingdom;Ezequiel Garcia Elorrio,Instit

140、ute for Clinical Effectiveness and Health Policy,Buenos Aires,Argentina;Adrian Gelb,World Federation of Societies of Anaesthesiologists(WFSA),London,United Kingdom;Charlotta George,Department of Knowledge Based Policy and Guidance,Stockholm,Sweden;Lena Graversen,Danish Patient Safety Authority,Copen

141、hagen,Denmark;Helen Haskell,Mothers Against Medical Error,Atlanta,United States;Kok Hian Tan,SingHealth Duke-NUS Institute for Patient Safety and Quality,Singapore,Singapore;Peter Hibbert,Australian Institute of Health Innovation,Macquarie University,Sydney,Australia;Carolyn Hoffman,Institute for Sa

142、fe Medication Practices,Ontario,Canada;Helen Hughes,Patient Safety Learning,London,United Kingdom;Beverley Hunt,ISTH,London,United Kingdom;Ingo Hartel,Federal Ministry of Health,Berlin,Germany;Tuija Ikonen,Centre for Client and Patient Safety,Helsinki,Finland;Lallu Joseph,Consortium of Accredited He

143、althcare Organizations,Noida,Uttar Pradesh,India;Niek Klazinga,OECD,Paris,France;Inge Kristensen,Danish Society for Patient Safety,Copenhagen,Denmark;Zuzana Kusynov,International Pharmaceutical Federation(FIP),The Hague,Netherlands(Kingdom of the);Basia Kutryba,National Centre for Quality Assessment

144、 in Health Care,Krakow,Poland;Peter Lachman,Royal College of Physicians of Ireland,Dublin,Ireland;Ronald Lavater,International Hospital Federation(IHF),Geneva,Switzerland;Piyawan Limpanyalert,The Healthcare Accreditation Institute,Bangkok,Thailand;Ivan Ludowyke,Ministry of Health,Colombo,Sri Lanka;M

145、eredith Makeham,University of Sydney,Australia;Jos Mara Valderas Martnez,World Organization of Family Doctors(WONCA),Zaragoza,Spain;Neda Milevska-Kostova,International Alliance of Patients Organizations(IAPO),London,United Kingdom;Xiao Mingchao,Hospital of Chongqing Medical University,China;Veronica

146、 Nyawira,Ministry of Health,Nairobi,Kenya;Lydia Okutoyi,Kenyatta National Hospital,Nairobi,Kenya;Helen Ong-Garcia,St Lukes Medical Center,Manila,Philippines;Nuria Prieto,Ministry of Health,Social Services and Equality,Madrid,Spain;Ioana Cristina Popescu,Healthcare Excellence Canada,Ottawa,Canada;Tho

147、mas Purchase,Cardiff University,United Kingdom;Jens Reventlov,Danish Society for|xviii|Global patient safety report 2024 Patient Safety,Copenhagen,Denmark;Bituin Reyes,Ministry of Health,Manila,Philippines;Mohammed Salah,Ministry of Health,Khartoum,Sudan;Caroline Samer,International Union of Basic a

148、nd Clinical Pharmacology(IUPHAR),Geneva,Switzerland;Kawaldip Sehmi,IAPO,London,United Kingdom;Yakob Seman Ahmed,Ministry of Health,Addis Ababa,Ethiopia;Sanjiv Sharma,Great Ormond Street Hospital London,United Kingdom;Susan Sheridan,Patients for Patient Safety-US,Idaho,United States;Anupam Sibal,Apol

149、lo Hospitals Group,New Delhi,India;Paulo Sousa,Universidade Nova de Lisboa Lisbon,Portugal;J N Srivastava,Quality and Patient Safety Division,National Health Systems Resource Centre,New Delhi,India;Anthony Staines,Federation of Vaud hospitals Lausanne,Switzerland;Julia Tainijoki-Seyer,World Medical

150、Association(WMA),Ferney-Voltaire,France;Patrizia Theurer,Ministry of Health,Vienna,Austria;Kate Trigg,Johns Hopkins Bloomberg School of Public Health,Baltimore,United States;Shin Ushiro,Kyushu University Hospital,Fukuoka City,Japan;Francesco Venneri,University of Florence,Italy;Sarah Yardley,Univers

151、ity College London,United Kingdom;Isaac Zrcher,Federal Office of Public Health,Bern,Switzerland.The WHO is grateful to Sir Liam Donaldson,WHO Director-General Special Envoy for Patient Safety,for his exceptional leadership and strategic guidance,which have significantly influenced the creation and r

152、eview of this global report.The development of this global report was made possible through WHO core funding.The WHO extends our sincere gratitude to the governments of the United Kingdom of Great Britain and Northern Ireland,Germany,and Switzerland for their substantial financial contributions to t

153、he WHO Patient Safety Flagship Unit.|xix|AbbreviationsADE adverse drug eventADR adverse drug reactionAEFI adverse events following immunizationAI artificial intelligenceAMR antimicrobial resistanceCDC Centers for Disease Control and PreventionCOVID-19 coronavirus disease-19DALY disability-adjusted l

154、ife yearECDC European Centre for Disease Prevention and ControlED emergency departmentEEA European Economic AreaEHR electronic health recordEU European UnionFIP International Pharmaceutical FederationGDP gross domestic productGPSC Global Patient Safety CollaborativeGPSN Global Patient Safety Network

155、GWP gross world productHCAI health care-associated infectionHIC high-income countryHIS health information systemHIV human immunodeficiency virusHSSIB Health Services Safety Investigations BodyHTA health technology assessmentIAPO International Alliance of Patients OrganizationsICM International Counc

156、il of MidwivesICN International Council of NursesICPS International Classification for Patient SafetyICU intensive care unitIEA International Ergonomics AssociationIHF International Hospital FederationILO International Labour OrganizationIPC infection prevention and controlAbbreviations|xx|Global pa

157、tient safety report 2024 IPSQ Institute for Patient Safety and QualityISQua International Society for Quality in Health CareISTH International Society on Thrombosis and HaemostasisIT information technologyIUPHAR International Union of Basic and Clinical PharmacologyIVD in vitro diagnosticsJHH Johns

158、Hopkins HospitalLIC low-income countryLMC lower middle-income countryLMIC low-and middle-income countryMoU memorandum of understandingNHS National Health ServiceNPSIF national patient safety implementation frameworkNQPS national quality policy and strategyNSA non-state actorNUS National University o

159、f SingaporeOECD Organisation for Economic Co-operation and DevelopmentPIDM Programme for International Drug MonitoringPFPS Patients for Patient SafetyPREM patient-reported experience measurePROM patient-reported outcome measurePSIRLS patient safety incident reporting and learning systemPV pharmacovi

160、gilanceQALY quality-adjusted life year ROI return on investmentSARS severe acute respiratory syndromeSDGs Sustainable Development GoalsSDI socio-demographic indexSOP standard operating procedureTCM traditional and complementary medicineTHB Thai BahtTB tuberculosisUHC universal health coverageUMC upp

161、er middle-income countryUNICEF United Nations Childrens FundUSAID United States Agency for International DevelopmentVTE venous thromboembolismWFME World Federation for Medical EducationWHO World Health OrganizationWMA World Medical AssociationWONCA World Organization of Family DoctorsWPSD World Pati

162、ent Safety DayWSFA World Federation of Societies of AnaesthesiologistsWTP willingness to pay|xxi|Glossary of termsTermDefinitionaccreditation A formal process by which a recognized body,usually a non-governmental organization,assesses and recognizes that a health care organization meets applicable p

163、re-and published standards.Accreditation standards are usually regarded as optimal and achievable,and are designed to encourage continuous improvement efforts within accredited organizations.An accreditation decision about a specific health care organization is made following a periodic on-site eval

164、uation by a team of peer reviewers,typically conducted every two to three years.Accreditation is often a voluntary process in which organizations choose to participate,rather than one required by law and regulation(1).adverse drug event(ADE)Any injury resulting from medical interventions related to

165、a drug.This includes both adverse drug reactions in which no error occurred and complications resulting from medication errors(2).adverse drug reaction(ADR)An adverse drug reaction is a response to a medicinal product that is noxious and unintended and which occurs at doses normally used in adults/c

166、hildren for the prophylaxis,diagnosis or therapy of disease or for the restoration,correction or modification of physiological function(3).adverse eventAn incident that resulted in harm to a patient(4).adverse events following immunization(AEFI)Any untoward medical occurrence that follows immunizati

167、on and which does not necessarily have a causal relationship with the usage of the vaccine.The adverse event may be any unfavourable or unintended sign,abnormal laboratory finding,symptom or disease(5).competencies The minimum set of competencies that constitute a common baseline for all health prom

168、otion roles(i.e.what all health promotion practitioners are expected to be capable of doing to work efficiently,effectively and appropriately in the field(6).digital healthThe field of knowledge and practice associated with the development and use of digital technologies to improve health.Digital he

169、alth expands the concept of eHealth to include digital consumers,with a wider range of smart-devices and connected equipment.It also encompasses other uses of digital technologies for health such as the Internet of things,artificial intelligence,big data and robotics(7).Glossary of terms|xxii|Global

170、 patient safety report 2024 TermDefinitiondisability-adjusted life years(DALYs)One DALY represents the loss of the equivalent of one year of full health.DALYs for a disease or health condition are the sum of the years of life lost due to premature mortality(YLLs)and the years lived with a disability

171、(YLDs)due to prevalent cases of the disease or health condition in a population(8).electronic health recordsReal-time,patient-centred records that provide immediate and secure information to authorized users.These typically contain a patients medical history,diagnoses and treatment,medications,aller

172、gies,immunizations,as well as radiology images and laboratory results.A national electronic health records system is most-often implemented under the responsibility of the national health authority and will typically make a patients medical history available to health professionals in health care in

173、stitutions and provide linkages to related services such as pharmacies,laboratories,specialists,and emergency and medical imaging facilities(9).haemovigilanceHaemovigilance is a set of surveillance procedures covering the entire transfusion chain,from the donation and processing of blood and its com

174、ponents,to their provision and transfusion to patients and their follow-up.It includes the monitoring,reporting,investigation and analysis of adverse events related to the donation,processing and transfusion of blood,and taking actions to prevent their occurrence or recurrence(10).health care-associ

175、ated infections(HCAIs)An infection occurring in a patient during the process of care in a hospital or other health care facility,which was not present or incubating at the time of admission.Health care-associated infections can also appear after discharge(11).health literacyThis represents the perso

176、nal knowledge and competencies that accumulate through daily activities and social interactions and across generations.Personal knowledge and competencies are mediated by the organizational structures and availability of resources that enable people to access,understand,appraise and use information

177、and services in ways that promote and maintain good health and well-being for themselves and those around them(12).health worker Health workers are all people engaged in work actions whose primary intent is to improve health,including doctors,nurses,pharmacists,midwives,public health professionals,l

178、aboratory,health and medical and non-medical technicians,community health workers,and healers and practitioners of traditional medicine.It also includes health management and support workers,such as hospital administrators,district health managers and social workers,cleaners,drivers,and other occupa

179、tional groups in health-related activities(13).human factorsStudy of the interrelationships between humans,the tools,equipment and methods they use,and the environments in which they live and work(4).in-service trainingTraining received while one is fully employed in the health sector.The aim is to

180、equip health workers or the trainers of health workers with the skills to deliver specific interventions(6).interprofessional educationFaculty and students from two or more health professions engaged in learning with,from,and about each other in all components of curricula including the practical on

181、es,to enable effective collaboration and improve health outcomes(6).just cultureAn environment that seeks to balance the need to learn from mistakes and the need to take disciplinary action(4).|xxiii|Glossary of termsTermDefinitionlicencing A government-endorsed regulatory process to grant permissio

182、n and specify scope for the health care practice of an individual or organization,usually preceding accreditation(14).medical deviceAn article,instrument,apparatus or machine that is used in the prevention,diagnosis or treatment of illness or disease,or for detecting,measuring,restoring,correcting o

183、r modifying the structure or function of the body for some health purpose.Typically,the purpose of a medical device is not achieved by pharmacological,immunological or metabolic means(15).medication errorAny preventable event that may cause or lead to inappropriate medication use or patient harm whi

184、le the medication is in the control of the health care professional,patient or consumer.Such events may be related to professional practice,health care products,procedures,and systems,including prescribing,order communication,product labelling,packaging,and nomenclature,compounding,dispensing,distri

185、bution,administration,education,monitoring,and use(16).medication-related harmThe harm caused by medication if taken incorrectly,monitored insufficiently or as the result of an error,accident or communication problem(17).never eventA patient safety incident that results in serious patient harm or de

186、ath(this refers to particularly shocking medical errors-such as wrong-site surgery,that should never occur)(18).palliative carePalliative care is an approach that improves the quality of life of patients(adults and children)and their families who are facing problems associated with life-threatening

187、illness.It prevents and relieves suffering through the early identification,correct assessment and treatment of pain and other problems,whether physical,psychosocial or spiritual(19).patient engagementThe facilitation and strengthening of the role of those using services as co-producers of health,an

188、d health care policy and practice(20).patient safetyPatient safety is a framework of organized activities that creates cultures,processes,procedures,behaviours,technologies and environments in health care that consistently and sustainably lower risks,reduce the occurrence of avoidable harm,make erro

189、r less likely and reduce impact of harm when it does occur(18).pharmacovigilanceScience and activities relating to the detection,assessment,understanding and prevention of adverse effects or any other drug-related problems(21).polypharmacyPolypharmacy is the concurrent use of multiple medications.Al

190、though there is no standard definition,polypharmacy is often defined as the routine use of five or more medications.This includes over-the-counter,prescription and/or traditional and complementary medicines used by a patient(3).preventable harmAccepted by the community as avoidable in the particular

191、 set of circumstances(4).primary careA key process in the health system that supports first-contact,accessible,continued,comprehensive and coordinated patient-focused care(15).resilienceAbility of all actors and functions related to health,to collectively mitigate,prepare,respond and recover from di

192、sruptive events with public health implications,while maintaining the provision of essential functions and services,and using experiences to adapt and transform the system for improvement(22).|xxiv|Global patient safety report 2024 TermDefinitionsentinel eventAn unexpected occurrence involving death

193、 or serious physical or psychological injury,or the risk thereof.Serious injury specifically includes loss of limb or function.The phrase“or risk thereof”includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome(18).sepsisLife-threatening org

194、an dysfunction caused by a dysregulated host response to infection(23).severe harmPatient outcome is symptomatic,requiring life-saving intervention or major surgical or medical intervention,shortening life expectancy or causing major permanent or long-term harm or loss of function.Severe harm result

195、s in permanent disability(4).transitions of careThe various points where a patient moves to,or returns from,a particular physical location or makes contact with a health care professional for the purposes of receiving health care(24).universal health coverage(UHC)Ensured access for all people to nee

196、ded promotive,preventive,resuscitative,curative,rehabilitative,and palliative health services,of sufficient quality to be effective,while also ensuring that the use of these services does not expose any users to financial hardship(15).Therapist assisting patient with balance exercises in a hospital

197、in Russia.WHO/Noor/Sebastian Liste|xxv|Glossary of terms1.Rooney AL,van Ostenberg PR.Licensure,accreditation,and certification:approaches to health services quality.Bethesda(MD):United States Agency for International Development;1999.2.Bates DW,Boyle DL,Vander Vliet MB,Schneider J,Leape L.Relationsh

198、ip between medication errors and adverse drug events.J Gen Intern Med.1995;10:199205.doi:10.1007/BF02600255.3.Medication safety in polypharmacy:technical report.Geneva:World Health Organization;2019(https:/iris.who.int/handle/10665/325454,accessed 5 May 2024).4.Conceptual framework for the internati

199、onal classification for patient safety version 1.1.Geneva:World Health Organization;2009(https:/iris.who.int/handle/10665/70882,accessed 5 May 2024).5.Global manual on surveillance of adverse events following immunization,2016 update.Geneva:World Health Organization;2016(https:/iris.who.int/handle/1

200、0665/206144,accessed 5 May 2024).6.Transforming and scaling up health professionals education and training.Geneva:World Health Organization;2013(https:/iris.who.int/handle/10665/93635,accessed 5 May 2024).7.Global strategy on digital health 20202025.Geneva:World Health Organization;2021(https:/iris.

201、who.int/handle/10665/344249,accessed 5 May 2024).8.The Global Health Observatory.Disability-adjusted life years(DALYs).In:Indicator metadata registry list.Geneva:World Health Organization;2015(https:/www.who.int/data/gho/indicator-metadata-registry/imr-details/158,accessed 5 May 2024).9.The Global H

202、ealth Observatory.Country has national Electronic Health Record(EHR).In:Indicator metadata registry list.Geneva:World Health Organization;2015(https:/www.who.int/data/gho/indicator-metadata-registry/imr-details/4791,accessed 5 May 2024).10.User guide for navigating resources on stepwise implementati

203、on of haemovigilance systems.Geneva:World Health Organization;2022(https:/iris.who.int/handle/10665/360060,accessed 5 May 2024).).11.Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level,World Health Organization;2016(https:

204、/iris.who.int/handle/10665/251730,accessed 5 May 2024).12.Health literacy development for the prevention and control of noncommunicable diseases:volume 1:overview.Geneva:World Health Organization;2022(https:/iris.who.int/handle/10665/364203,accessed 5 May 2024).13.Patient safety rights charter.Genev

205、a:World Health Organization;2024(https:/iris.who.int/handle/10665/376539,accessed 5 May 2024).14.Global patient safety action plan 20212030:towards eliminating avoidable harm in health care.Geneva:World Health Organization;2021(https:/iris.who.int/handle/10665/343477,accessed 5 May 2024).15.Operatio

206、nal framework for primary health care:transforming vision into action.Geneva:World Health Organization and the United Nations Childrens Fund(UNICEF);2020(https:/iris.who.int/handle/10665/337641,accessed 5 May 2024).16.About medication errors.What is a medication error?Rockville(MD):National Coordina

207、ting Council for Medication Error Reporting and Prevention;2019(http:/www.nccmerp.org/about-medication-errors,accessed 5 May 2024).17.Global burden of preventable medication-related harm in health care:a systematic review.Geneva:World Health Organization;2023(https:/iris.who.int/handle/10665/376203,

208、accessed 5 May 2024).18.Patient safety incident reporting and learning systems:technical report and guidance.Geneva:World Health Organization;2020(https:/iris.who.int/handle/10665/334323;accessed 5 May 2024).19.Quality health services and palliative care:practical approaches and resources to support

209、 policy,strategy and practice.World Health Organization;2021(https:/iris.who.int/handle/10665/345674,accessed 5 May 2024).References for the glossary|xxvi|Global patient safety report 2024 20.Technical series on safer primary care:Patient engagement.Geneva:World Health Organization;2016(https:/iris.

210、who.int/handle/10665/252269,accessed 5 May 2024).21.The importance of pharmacovigilance:safety monitoring of medicinal products.Geneva:World Health Organization;2002(https:/iris.who.int/handle/10665/42493,accessed 5 May 2024).22.Health systems resilience toolkit:a WHO global public health good to su

211、pport building and strengthening of sustainable health systems resilience in countries with various contexts.Geneva:World Health Organization;2022(https:/iris.who.int/handle/10665/354177,accessed 5 May 2024).23.Singer M,Deutschman CS,Seymour CW,Shankar-Hari M,Annane D,Bauer M et al.The third interna

212、tional consensus definitions for sepsis and septic shock(Sepsis-3).JAMA.2016;315:80110.doi:10.1001/jama.2016.0287.24.Technical series on safer primary care:Transitions of care.Geneva:World Health Organization;2016(https:/iris.who.int/handle/10665/252272,accessed 5 May 2024).|xxvii|Executive summaryE

213、xecutive summaryThe pursuit of universal health coverage is aimed at ensuring every person and community has access to safe and quality health care without facing financial strain.The key to realizing this vital goal lies in ensuring the safety of health services.Without this,the full potential of e

214、xpanded coverage will be lost,leading to a decline in trust and a reluctance to seek care,even when it is most needed.Recognizing this crucial need,the Seventy-second World Health Assembly(2019)adopted the resolution WHA72.6 entitled Global action on patient safety.This resolution emphasizes the cri

215、tical role of patient safety in the establishment,functioning and evaluation of all health care systems.It reasserts the foundational principle of First,do no harm,underscoring the imperative to enhance patient safety in health systems across all dimensions,sectors and environments,encompassing both

216、 physical and mental health.The resolution called upon the Director-General of the World Health Organization(WHO)to develop a comprehensive global patient safety action plan,in collaboration with Member States and all relevant stakeholders.In 2021,the Seventy-fourth World Health Assembly also made a

217、 pivotal decision to adopt the Global patient safety action plan 20212030.This decision also included a request for the Director-General to regularly report to the Assembly on progress in the implementation of the action plan,starting in 2023 and continuing every two years until 2031.In response to

218、this directive,the WHO secretariat initiated a global patient safety survey for Member States in 2022.An interim report,based on an initial analysis of the data received in response to the survey,was presented to the World Health Assembly in May 2023.This first Global patient safety report presents

219、a comprehensive global overview,highlighting a wide range of patient safety initiatives and progress made around the world alongside the challenges encountered.The Global patient safety report provides a foundational understanding of the current state of patient safety globally.It contains insights

220、and information beneficial to health care professionals,policy-makers,patients and patient safety advocates,researchers essentially anyone involved or interested in the improvement of health care and patient safety globally.It offers insights into specific areas that need attention and investment,re

221、cognizing that progress in patient safety measures has been uneven across different regions.The methodology of the report is grounded in the first ever global patient safety survey conducted by the WHO.This survey was a pivotal effort in assessing the implementation of the action plan across Member

222、States.Unsafe care is a major public health problem that affects millions of patients worldwide,with estimates suggesting that more than one in ten patients suffer from adverse events.The severity of nearly half of patient harm extends beyond mild injuries and temporary harm.As much as 12%of harm ca

223、uses permanent disability or patient death.Latest estimates indicate that unsafe care causes more than 3 million deaths every year globally,and that around half of all harm due to unsafe care is preventable.|xxviii|Global patient safety report 2024 Patient harm due to unsafe care also causes irrever

224、sible reputational damage to health care systems,detrimentally affecting patient experience,trust and engagement with health care services,the morale and well-being of health care workers and public opinion about the value of investing precious societal resources in health care systems.Around two th

225、irds of all patient harm due to unsafe care and the resulting years lost to disability and death occur in low-and middle-income countries(LMICs).Each year,134 million adverse events occur in hospitals in LMICs,contributing to approximately 2.6 million deaths.Unsafe care in health care systems incurs

226、 significant financial and economic costs.It leads to additional medical interventions,consuming resources that could be allocated elsewhere.In high-income countries(HICs),unsafe care can account for a substantial portion of total health expenditure,with recent analysis indicating about 15%of health

227、 spending goes to managing the consequences of patient harm.The direct financial impact is considerable,affecting both acute and long-term care sectors.Studies in LMICs,though limited,suggest similar cost implications.In health care,acute care settings(e.g.hospitals)bear high costs due to safety lap

228、ses such as infections,medication errors and surgical complications.Costs include increased hospital stays and treatment expenses,significantly impacting health care budgets.Primary and ambulatory care also face substantial costs from medication and diagnostic errors.Long-term care settings incur co

229、sts due to adverse events such as pressure ulcers and falls.Overall,the direct costs of patient harm are substantial and likely underestimated,while indirect costs like lost productivity can exceed direct costs.Patient harm significantly impacts productivity and labour supply,with indirect costs oft

230、en exceeding direct health care costs.Studies using the human capital approach highlight substantial productivity loss and income reduction due to patient harm.This impact is more pronounced in socially and economically disadvantaged groups.The overall economic burden of patient harm is considerable

231、,comparable to major chronic diseases such as diabetes,reducing global economic output significantly.These costs,while variable in different studies,underscore the extensive economic consequences of unsafe health care practices.Investing in patient safety interventions offers a high return on invest

232、ment and is cost-effective compared to other medical services.Strategies targeting common and harmful events such as infections,medication errors and pressure ulcers are particularly valuable.Technological solutions such as barcode systems are effective in reducing medication errors.Additionally,eng

233、aging patients and improving health literacy can substantially decrease harm and associated economic burdens,benefiting both patients and health care systems.Summary of findingsThis global report explores the global patient safety situation,offering a comprehensive and detailed analysis of Member St

234、ate survey data as well as other published sources.It presents a global overview,highlighting a wide range of patient safety initiatives and progress made around the world,in line with the strategic framework and suggested actions and its 7x5 matrix outlined in the Global patient safety action plan

235、20212030.The structure of the report directly aligns with the strategic objectives of the action plan,focusing on the implementation of strategies across nations to enhance patient safety.Policies to eliminate avoidable harm in health care(strategic objective 1)Although most countries recognize pati

236、ent safety as a national health priority,only one third of countries have fully incorporated patient safety into their national strategies for achieving UHC.The development of policies,strategies,action plans,and programmes for patient safety is still in its early stages,and an even smaller fraction

237、 of countries report having adequate financial and human resources for implementation.|xxix|Executive summaryRegulatory mechanisms such as mandatory licensing of health care facilities are widely used to enforce safety,with a significant number of countries enacting laws on the use of medical produc

238、ts and implemented the safety standards in health care facilities.World Patient Safety Day,established in 2019,has created unprecedented international momentum with 80%of Member States actively participating in annual campaigns and events to enhance awareness of patient safety.The WHO Global Patient

239、 Safety Challenges address critical risks to patient health and safety.Countries have taken actions on these initiatives,with almost 90%of countries addressing at least one of the challenges and one third of the countries implementing all the three challenges.High-reliability systems(strategic objec

240、tive 2)A safety culture in health care is recognized as crucial by most countries,yet only a quarter of countries reported to have made efforts towards developing a culture of safety in health care facilities and services.The WHO Global patient safety action plan 20212030 advocates for good governan

241、ce in patient safety,with around half of the countries having designated national patient safety officers and establishing national coordination bodies.Although the significance of human factors in health care is increasingly being acknowledged globally,only around a quarter of countries have starte

242、d to implement human factors principles in patient safety measures in clinical practice,use of medical devices,information technology solutions,and service delivery processes.A proactive and systematic approach to managing patient safety risks involves meticulous identification,examination and mitig

243、ation of potential hazards and risks in health care settings.Only a quarter of countries report implementation of risk management strategies and conduct regular mock drills.Most countries have established physical safety norms for health care infrastructure,but only about half report enforcing these

244、 norms,highlighting a gap between policy and practice in infrastructure safety.Safety of clinical processes(strategic objective 3)Around 41%of countries have launched patient safety improvement programmes tailored to their specific contexts,addressing different sources of harm.Health care-associated

245、 infections and medication errors are prioritized in the majority of countries implementing such initiatives.Two thirds of countries have endorsed and are implementing the third WHO Global Patient Safety Challenge:Medication Without Harm.However,only a quarter of countries are actively addressing al

246、l three priority areas of the Challenge:high-risk situations,transitions of care,and polypharmacy.Around 60%of the countries report having a national programme for infection prevention and control,and half of the countries report implementing active surveillance systems for health care-associated in

247、fections.Countries have made significant investments in ensuring the safety of medical products.Almost all countries have functional pharmacovigilance programmes,nearly 80%have implemented blood safety programmes,and about half of the countries have initiatives for the safety of medical devices.Pati

248、ent safety in primary and ambulatory care is less prioritized compared to safety in hospitals,with only 17%of countries systematically including safety in primary care programmes.Patient and family engagement(strategic objective 4)Patients and their families are key partners in creating and executin

249、g policies and action plans for patient safety.However,only 13%of countries have appointed a patient representative to the governing board of the majority of their hospitals.|xxx|Global patient safety report 2024 Countries have recognized patient rights charters as a means of empowering patients,and

250、 around 70%of countries have either developed or are in the process of developing such charters at the national level.Collecting feedback from users on safety and service quality is a common practice for improving services.80%of countries have mechanisms in place to gather such feedback,with nearly

251、20%also measuring patient-reported care outcomes.Access to medical records is recognized as a key patient right.Around 80%of countries report having procedures in place for patients and families to access their medical records,although only 50%have taken proactive actions to inform patients about th

252、e procedures for accessing patients medical records.Health care organizations should have policies to promote transparency,including full disclosure if patients are harmed in health care.However,only a quarter of countries have established procedures for disclosing adverse events to patients and fam

253、ilies.Increasing public awareness and education about patient safety is of paramount importance for making health care safer.While two thirds of countries have developed information and educational materials only 14 of countries have launched a focused campaign to provide information and education t

254、o patients and families for their involvement in self-care and empower them for shared decision-making.Health worker education,skills and safety(strategic objective 5)Understanding of patient safety is essential for all health workers,yet comprehensive integration of patient safety in health profess

255、ional education and training remains limited globally.Only around one fifth of countries have incorporated patient safety in their undergraduate and postgraduate professional education.While a quarter of countries provide specialized in-service training courses on patient safety,there is a significa

256、nt global shortage of trainers on patient safety,with 14%of countries reporting sufficient training capacity.A quarter of countries have established patient safety competencies for all categories of health workers,and only in 14%of the countries core competencies for patient safety are incorporated

257、in licensing and re-licensing requirements.There is a strong interdependence between patient safety and health worker safety that was highlighted during the COVID-19 pandemic,leading to increased national efforts in ensuring health workers health and safety.Around 70%of countries have established or

258、 are working towards establishing a national programme for occupational health and safety of health workers.While WHO recommends vaccination for all at-risk health workers,coverage of health workers against vaccine-preventable diseases,as per the national immunization policy,is reported by nearly 55

259、%of the countries.Information,research and risk management(strategic objective 6)Although patient safety incident reporting and learning systems have been introduced in 70%of countries,their effectiveness remains limited,and only in one third of countries do the majority of health care facilities ac

260、tively report safety incidents to these systems.Interoperability and international collaboration for sharing data between patient safety incidents reporting systems are limited,with only around one third of countries aligning their reporting formats with the WHO minimum information model.The impleme

261、ntation of electronic health records(EHR)in health care systems is increasingly recognized,with nearly 90%of countries reporting their adoption.However,full integration of EHR with health care processes is reported by only one quarter of countries.|xxxi|Executive summaryThree quarters of countries h

262、ave identified patient safety indicators,yet only a minority integrate these into health information systems or publish annual safety reports,indicating a gap in data utilization for safety improvement.Research on patient safety remains a low priority,with only 11%of countries considering it a prior

263、ity,although some integrate safety risk assessments in health technology evaluations.Synergy,partnerships and solidarity(strategic objective 7)Enhancing patient safety and care quality through stakeholder engagement remains an evolving endeavour.Though around one-third of countries have identified k

264、ey stakeholders,only 17%have implemented effective coordination mechanisms to fully engage these stakeholders.Professional associations and academic institutions are widely involved in patient safety efforts in most countries,indicating strong multisectoral collaboration.Countries are increasingly i

265、nvolved in global and multilateral discussions on patient safety,with around three quarters of countries participating in global ministerial summits on patient safety.Nearly 20%of countries report having established patient safety networks that facilitate programme coordination and sharing of best p

266、ractices.Despite the growing recognition of the private sector as a key stakeholder in patient safety,there remains significant room for improvement in their involvement.While 65%of countries acknowledge private sector and industry as key stakeholders,only 12%actively engage them in their national p

267、atient safety initiatives.Fig.Global status on progress on strategic objectives of Global patient safety action plan 20212030(performance scores out of 100)560Policies to eliminateavoidable harm in healthcare(strategic objective 1)High-reliability systems(strategic objective 2)Safety of c

268、linicalprocesses(strategicobjective 3)Patient and familyengagement(strategicobjective 4)Health worker education,skills and safety(strategic objective 5)Information,research and risk management(strategic objective 6)Synergy,partnershipsand solidarity(strategic objective 7)|xxxii|Global patient safety

269、 report 2024 Progress in achieving the core indicators129%Proportion of countries that have developed a national patient safety action plan or equivalent20%Proportion of countries that have incorporated a patient safety curriculum in education programmes or courses for health care professionals38%Pr

270、oportion of countries that have established their national targets on reducing health care-associated infection rate18%Proportion of countries that publish an annual report on patient safety13%Proportion of countries that have a patient representative on the governing board(or an equivalent mechanis

271、m)in 60%or more hospitals21%Proportion of countries that have established a national patient safety network38%Proportion of countries that have implemented a system for reporting of never events(or sentinel events)21%Proportion of countries that have established their national targets on reducing me

272、dication related harm32%Proportion of countries that have 60%or more health care facilities participating in a patient safety incident reporting and learning system18%Proportion of countries that have signed up for implementation of the WHO Health Worker Safety Charter1 These percentages refer only

273、to the 108 countries that completed the survey.Portrait of a nutritionist at a hospital in Kenya.WHO/Billy MiaronIntroductionPortrait of an elderly woman at her home in Viet Nam after her annual eye check-up.WHO/Sebastian Meyer|3|IntroductionBackground The pursuit of universal health coverage(UHC)is

274、 a vital and noble endeavour,aimed at ensuring every person and community has access to safe and quality health care without facing financial hardship.The key to realizing this sustainable development goal(SDG)target lies in ensuring the safety of health services.Without this,the full potential of e

275、xpanded coverage will be lost,leading to a decline in trust and a reluctance to seek care,even when it is most needed.Recognizing this crucial need,the Seventy-second World Health Assembly(2019)adopted the landmark resolution(WHA72.6),entitled Global action on patient safety(1).This resolution empha

276、sizes the critical role of patient safety in the establishment,functioning and evaluation of all health care systems.It reasserts the foundational principle of First,do no harm,underscoring the imperative to enhance patient safety in health systems across all levels,settings and sectors,encompassing

277、 both physical and mental health.The resolution called upon the Director-General of the World Health Organization(WHO)to develop a comprehensive global patient safety action plan,in collaboration with Member States and all relevant stakeholders.In 2021,the Seventy-fourth World Health Assembly made a

278、 pivotal decision of adopting the Global patient safety action plan 20212030(2).This decision also included a request for the Director-General to regularly report to the World Health Assembly on progress in the implementation of the action plan,starting in 2023 and continuing biennially until 2031.I

279、n response to this directive,the WHO secretariat initiated a global patient safety survey for Member States in 2022.An interim report,based on an initial analysis of the data received in response to the survey,was presented to the 76th World Health Assembly in May 2023(3).The current global report e

280、xplores the global patient safety situation more extensively,offering a comprehensive and detailed analysis of the Member State survey data as well as other published sources.What this report is aboutThis report presents a comprehensive global overview of the status of patient safety implementation

281、across the world,specific regions and individual countries.The report is closely aligned with the strategic framework of the Global patient safety action plan 20212030.It provides an in-depth look at how countries are addressing challenges and implementing actions to strengthen patient safety throug

282、h multiple dimensions such as policies,strategies,plans,legislation,regulations,programmes,practices,initiatives,coordination mechanisms,investments,international collaborations,clinical programmes,education,and more.The aim is to present a broad perspective on the state of patient safety on a globa

283、l scale,highlighting both the progress made and persistent challenges and opportunities for improvement.WHA resolution Global Action on Patient Safety emphasizes prioritizing patient safety globally.Subsequent adoption of the Global Patient Safety Action Plan 20212030 reaffirms this commitment and m

284、andates biennial reporting on its implementation.The report provides a global perspective on patient safety implementation,in line with the Global Patient safety action plan 20212030.|4|Global patient safety report 2024 The contents of this report encompass:An analysis that compiles and describes ac

285、tions taken by countries,including the summary of these actions across different WHO regions and income levels based on Member State survey.An in-depth summary presenting evidence on the overall burden of unsafe health care practices,viewed broadly as well as within specific population groups,clinic

286、al domains,and according to major sources of harm.Case studies showcasing how different countries are learning and developing patient safety solutions within their unique contexts,along with feature stories highlighting key global initiatives and interventions in patient safety.Comparative analyses

287、offering deeper insights into crucial areas such as patient safety policies,legal frameworks,patient involvement,educational initiatives,reporting and learning systems,and the involvement of various stakeholders.Who this report is for Considering patient safety is a universal concern,this report is

288、relevant and valuable for a wide range of audiences.It contains insights and information beneficial to health and care workers,policy-makers,patients and their advocates,researchers essentially anyone involved or interested in the improvement of health care and patient safety globally.Policy-makers

289、and health care leaders:The report provides a global perspective on patient safety strategies,identifying where efforts are thriving and where gaps exist.It comprises an overarching view of global trends in patient safety strategies,highlighting the gaps and strengths in different regions.Such insig

290、hts are vital for policy-makers,health care and political leaders to effectively prioritize and formulate their strategic and operational approaches.For political leaders in particular,the report offers understanding in shaping public policy and legislation,aligning health policies with the latest g

291、lobal trends in patient safety.Furthermore,the report facilitates international collaboration,helping leaders to engage in global health initiatives and share best practices across borders.International organizations and developmental partners:For bilateral and multilateral organizations,non-governm

292、ental entities,as well as national and international developmental partners,donors and funding agencies,the report serves as an important tool.It guides them in identifying specific areas of patient safety that require more attention,resources and funding,thereby ensuring that their investments yiel

293、d substantial impacts on health care safety and quality.Research and academic institutions:The report is a useful reference for institutions engaged in patient safety education and research and related fields.It helps in identifying emerging areas where evidence is lacking,pointing out the need for

294、further research to enhance the implementation of patient safety strategies and interventions.It offers insights into global patient safety strategies,helping leaders prioritize and shape approaches.It also guides developmental partners in identifying areas needing furthermore attention.The report c

295、overs a comprehensive analysis of global patient safety efforts,including actions taken by countries,the burden of unsafe health care practices,case studies and comparative analyses.|5|IntroductionHealth care organizations and managers:Even though the report primarily focuses on national aggregated

296、data,it offers valuable insights for health care organizations and facility managers.They can use this data to understand the broader context of patient safety and initiate targeted actions in their areas of work.Health care industry:The report serves as a useful resource for health care corporation

297、s,pharmaceutical companies,medical device manufacturers and digital industry,offering deeper understanding for strategic foresight and planning.It guides these industries in aligning their product development,innovation strategies and market expansion plans with current patient safety needs and chal

298、lenges,facilitating global compliance and the adoption of best practices.Patients,communities and advocacy groups:Ultimately,the report is profoundly relevant to patients,families and communities as the end-users of health care.It empowers patient organizations,consumer groups,patient advocates and

299、champions to advocate for safer health care.By understanding the complexities involved in ensuring safe care,they can become more effectively engaged in the pursuit of safer health care,from policy dialogues to practice at the point of care.How this report was developed The approach for assessing pa

300、tient safety progress was intricately developed alongside the strategic framework of the Global patient safety action plan 20212030.The action plan outlines 10 core indicators(see Annex 1)and a set of advanced indicators,all aligned with each of the plans seven strategic objectives.Following the dir

301、ective from the World Health Assembly in 2021,the WHO secretariat promptly began crafting a comprehensive framework and tools to assess progress against the global action plan.This involved consulting with leading global experts to devise a practical and scientifically robust method for tracking pro

302、gress.It was decided that the WHO secretariat would conduct a structured patient safety survey with Member States to evaluate implementation of the suggested actions in the action plan.This initial survey was designed to establish a set of baseline data,with subsequent surveys every two years coinci

303、ding with the reporting cycle to the World Health Assembly.The WHO secretariat then developed the initial version of the global patient safety assessment tool,which underwent several rounds of refinement with input from global experts and technical teams within WHO headquarters and regional offices.

304、The survey,designed for self-assessment,aims to catalyse action for enhancing patient safety and foster a policy environment conducive to establishing a safety culture and sustainable patient safety programmes.Initiated in October 2022 and available in all six UN official languages,the survey on the

305、 WHO Dataform platform required each Member State to designate an officer within their health ministry to oversee and respond to the assessment tool.The Patient Safety Flagship unit at WHO headquarters took global This report is a vital resource for various stakeholders,including research institutio

306、ns,health care organizations,industry players and advocacy groups.By providing insights into global patient safety strategies and identifying areas for improvement,it empowers stakeholders to drive positive change in health care safety and quality.The WHO conducted a patient safety survey with Membe

307、r States to assess progress on the Global patient safety action plan 20212030.This survey,will be repeated every two years for reporting to the World Health Assembly.|6|Global patient safety report 2024 leadership in centrally coordinating the survey,in close collaboration with WHO regional and coun

308、try offices.It also facilitated various information sessions and capacity-building initiatives for Member States,aimed at enhancing the quality and thoroughness of their responses.Recognizing the integral role of patient safety in all aspects of clinical and health programmes,the survey emphasized t

309、he need for collaboration and information exchange with a range of organizations and institutions.To facilitate effective data collection,small working groups were established within countries to consolidate information from multiple sources.The process of nominating officers and managing survey res

310、ponses was coordinated by the health ministries of each country,in collaboration with the relevant WHO regional and country offices,as applicable.The development of this report,including data analysis and writing,was a collaborative effort coordinated by the WHO Patient Safety Flagship unit at WHO h

311、eadquarters.It involved contributions from several technical units within the organization,as well as a network of global experts and academic partners,ensuring a comprehensive and expert-driven approach.Patient safety is fundamentally focused on enhancing the safety of patients and accordingly pati

312、ents representatives played an active role in the development of the survey tool,participated in consultations,and contributed to both writing and reviewing of this report,ensuring that their perspectives and experiences were integral throughout the process.All external experts submitted to WHO a de

313、claration of interest disclosing potential conflicts of interest that might affect,or might reasonably be perceived to affect,their objectivity and independence in relation to the subject matter of the meeting/guidance.WHO reviewed each of those and had concluded that none could give rise to a poten

314、tial or reasonably perceived conflict of interest related to development of this report.Survey toolThe global patient safety assessment tool was meticulously developed to objectively evaluate the progress in implementing the strategic framework of the Global patient safety action plan 20212030.The d

315、esign of the tool aligns with the 7 x 5 strategic matrix of the action plan(see Annex 2),encompassing seven strategic objectives and 35 corresponding strategies.Five assessment criteria were assigned to each strategy,culminating in a comprehensive set of 175 criteria focused on specific suggested ac

316、tions.For every criterion,respondents were tasked with evaluating their countrys current status and responding with one of three options:fully met;partially met;or not met.Clear guidelines were provided for each criterion to determine the performance level defined for meeting each benchmark.Addition

317、ally,in cases where a criterion may not be relevant or applicable to a countrys specific context,respondents had the option to mark it as not applicable.The survey highlighted collaboration among organizations for the purposes of effective data collection.Small working groups within countries consol

318、idated information,coordinated by health ministries and WHO offices.The survey tool aligns with the strategic framework of the Global patient safety action plan 2021-2030,featuring seven objectives,35 strategies,and 175 specific assessment criteria.It enables respondents to evaluate their countrys p

319、rogress for each criterion.|7|IntroductionMeasuring performanceThe global patient safety assessment tool was primarily designed to support the survey and to provide an overview of the progress made in the implementation of the Global patient safety action plan 20212030,and importantly to stimulate a

320、ction at the country level.The tool is completed through self-assessment,enabling countries to identify their areas of relative strength and where further action is needed.The report also leverages the aggregated survey data set to facilitate insightful analysis across various WHO regions and World

321、Bank income groups,aiming to highlight overarching trends,priorities and gaps on a global and regional basis.However,it is important to note that the survey and its measurement approach are not intended for making country comparisons,as each country faces unique challenges in maintaining safety with

322、in its health care system.This makes a universal comparison index less practical given the inherent reduction of national complexities and validity problems.The report provides global,regional and income group scores at the start of each strategic objective section,and how these scores have been cal

323、culated is outlined below.a.Scores for strategic objectivesEach strategic objective includes five strategies,with a total of 25 criteria.For every criterion,a score is assigned as follows:2 for fully met,1 for partially met,and 0 for not met.Responses marked as not applicable are excluded from the s

324、coring.Thus,the maximum possible score for each strategic objective is 50.To enhance clarity,these scores are calculated out of 100.b.Scores for strategiesEach strategy encompasses five criteria,meaning the maximum score for a given strategy is 10.The scores for strategies are presented as actual sc

325、ores obtained(i.e.out of 10).It is important to note that overall scores are derived by averaging the responses that were either partially met or fully met.However,for individual criteria,the performance is based solely on the number of countries that reported fully met for each criterion.Response c

326、haracteristics of the survey The survey invited participation by all 194 WHO Member States and three associate members.Of these,141 Member States initiated the survey process,and 108 of these ultimately submitted their responses.For the purposes of analysis,only the surveys that were completed and s

327、ubmitted were taken into consideration.The data presented in the report reflect responses provided by countries between November 2022 and May 2023.Countries from across The survey tool facilitates analysis across WHO regions and income groups but is not intended for country comparisons due to the un

328、ique challenges faced by every nation.The survey invited all 194 WHO Member States and three associate members to participate.Ultimately,108 responses were completed and submitted.|8|Global patient safety report 2024 all six WHO regions took part in the survey,although response rates varied by regio

329、n(Fig.1).This variance in participation levels,offers valuable insights into the global engagement and commitment to the principles and practice of patient safety.28Number of countriesAfricanRegionRegion of theAmericasSouth-East Asia Region EuropeanRegion Eastern MediterraneanR

330、egion Western PacifcRegion 00Total countriesSurvey completedThe countries that responded to the survey were representative of all World Bank income groups,although the response rates were marginally higher among high-income countries(HICs)(Fig.2)(4).Number of countriesTotal countriesSurve

331、y completed43628High-incomecountriesUpper middle-incomecountriesLower middle-incomecountriesLow-incomecountries0070Patient safety represents a vital concern in public health,with policies,programmes and initiatives at the country level having a direct impact on patients,their f

332、amilies and the broader population.Based on responses from 108 countries,the findings of this report encompass approximately 84%of the global population.Fig.1.Number of countries that responded the Member State survey,by WHO region Fig.2.Number of countries that responded to the Member State survey,

333、by World Bank income country classification 20222023The findings of this report,based on responses from 108 countries,cover about 84%of the global population.|9|IntroductionLimitations As the first WHO Global report on patient safety,this report primarily offers a cross-sectional snapshot of the current status of patient safety across the world,based on the data provided by WHO Member States.This