Global State of Patient Safety 2023

1. Executive Summary

The Institute of Global Health Innovation at Imperial College London, commissioned by Patient Safety Watch, presents this analysis of the Global State of Patient Safety 2023.

Patient Safety Country Ranking

Our novel patient safety country ranking compares the performance of OECD countries across four well-established patient safety indicators, following the methodology used by the Commonwealth Fund. Using this approach, Norway is at the top of the ranking. The UK ranks 21^st out of 38 countries.

The ranking also highlights the variation that exists across comparable countries. Using only the four selected metrics, we see that the UK could have had 17,356 fewer deaths annually had it performed at the level of the top decile of OECD countries.

Broken down by indicator,  this would have meant 15,773 fewer deaths classified as “treatable mortality” (where the cause of death can be mainly avoided through timely and effective health care interventions) per year, 776 fewer deaths due to neonatal disorders per year, 27 fewer maternal deaths per year and 780 fewer deaths due to adverse effects of medical treatment per year.

An important limitation of this ranking is that the four indicators included only represent a narrow aspect of health system performance, and do not consider the wider quality of life effects or long-term disability caused by unsafe care. More comprehensive, consistently collected and regularly shared data would significantly increase the opportunity for cross-country comparisons and shared learning.

Patient Safety Dashboard

Our Purpose-built patient safety data dashboard, provides a single point of access to publicly available global patient safety data. An analysis of this data paints a less than optimistic picture of global patient safety over the past decade.

Many of the indicators show very little overall improvement over time. An example is performance on retained item during surgery, despite being subject to significant focus and improvement efforts.

Many indicators also show a significant spread in performance, even between comparable groups of countries. One example is the rate of maternal sepsis, which shows a 437-fold difference between the top and bottom 10% of countries.

Rates of progress, and levels of variation, can to some extent be explained by improvements in reporting practices, or contextual differences between countries.

We present this analysis, and the accompanying data dashboard, to highlight the opportunities for improving patient safety by systematically comparing data and sharing examples of excellence between countries.

Our analysis is, however, limited by the lack of timely, relevant and comparable data at a global level. We find, for example, that:

• Three out of every five indicators are not available for low or low-middle income countries (LMIC).
• One in every six indicators consists of data more than three years old.
• Only one in every ten indicators comprises data directly reported by patients.

In addition, we would also want to see further work to collect data on:

• The patient’s trajectory of care through different care providers, and
• Any inequities in safe care on account of peoples’ demographic characteristics or socio-economic circumstances.

Case Studies

Our case studies showcase excellence in safety measurement and improvement from the patient, family and carer perspective. These insights from nine leading patient safety experts and practitioners provide optimism on how deficiencies in patient safety data can be addressed. The challenge remains in how to foster the effective adoption of these approaches and interventions globally.

Recommendations

Based on our findings, we set out three recommendations to improve the measurement of patient safety:

1. Assessment: A more balanced and comprehensive set of global patient safety indicators is required to address the data gaps identified in this report, and to ensure comparable data is available for all countries. Consensus is required on the minimum set of indicators that all countries should report on.
2. Adoption: A global repository of safety measurement and improvement interventions should be developed and made freely available to frontline teams of practitioners and researchers across the world.
3. Activation: To ensure the faithful adoption of interventions, patients, families and carers must be given the agency to become active and equal partners in the delivery of safe care.

2.1 Opening remarks by Deborah E Prowse, KC, Patient Safety Advocate

4.1 The global burden of harm

Estimates of the global burden of harm caused by heath care emphasise the scale of the problem. In 2019, research estimated the prevalence of preventable patient harm across medical care settings to be 6%, translating to around 1 in 20 patients being exposed to harm. In 2013, estimates suggested that at least 43 million injuries each year were due to medical care, with 23 million lost DALYs (Disability-Adjusted Life Years, each one representing the equivalent of losing one year of full health), the majority of which occurring in low- and middle- income countries and economies in transition. One in 10 dollars spent on health care globally is diverted to treating the effects of unsafe care and reduces global economic output by trillions of dollars each year.

In some areas progress in patient safety has stalled, with the decline in maternal deaths slowing from an annual rate of reduction of 2.7% between 2000 to 2015, to 0.04% between 2016 and 2020. The COVID-19 pandemic has had a significant effect on progress and also served to deepen inequities. For example, in the US, the number of maternal deaths rose from 754 in 2019 to 1,178 in 2021. The maternal mortality ratio for non-Hispanic black women was 68.9 per 100,000 live births in 2021, and 26.1 for non-Hispanic white women.

Alongside the ever-increasing demands being placed on the health care workforce to meet the needs of patients and populations, there are several reasons for this plateauing in safety improvement. They include:

• A realisation that Quality Improvement methods are not a panacea, and often do not lead to the wider cultural change required for substantive impact, or stand up to evaluation in a wider context;
• An enthusiastic, but superficial, embrace of principles and methods from the safety sciences, without the deeper work they often require, as demonstrated in other safety-critical industries;
• A lack of recognition and prioritisation of the importance of quality and safety as a key component of universal health coverage, resulting in limited investment and attention particularly in resource constrained settings and;
• The impact of the COVID-19 pandemic, putting the workforce and entire health and care system under almost unimaginable stress, leading to re-directed attention and resources, and significant backlogs in care for cancer and other specialised treatments.

There has also been an increasing recognition of the nature and extent of compounded harm that can arise following injury, as a consequence of the way that health and care services respond to a patient safety incident (see case studies 1 and 2 below). Responses to harm that are not open or transparent, or do not seek to understand what patients and families need to support their healing and recovery, are entirely avoidable. Responses to harm must focus on learning to prevent future harm, but this need not be at the expense of decent, and empathetic, involvement of all those affected.

Case study 1: Involving patients in safety investigations.

The Learn Together project aims to develop guidance to ensure more meaningful involvement in the investigation of serious healthcare incidents. The idea was that, by working relationally between patients, families and staff, the likelihood of compounded harm – where the harm relating to a patient safety event is compounded by the processes that follow it – is reduced.

A series of resources, free to download, have been designed for patients and families, and those investigating safety incidents, based on a set of common principles co-developed with these groups. These include a guide providing support for patients and families going through the process of a safety investigation, which includes space for patients and families to record key information about the investigation. Additional resources include a guide for investigators, as well as videos and links to other support and resources.

Case study 2: Restoration and healing from harm

There is also a widening gap between countries at different stages of their patient safety journeys, and between those from high- and low-resource settings. Some of this is evident in the data dashboard. As countries strive towards achieving the Sustainable Development Goals (SDGs), the benefits of having access to health services is undermined by unsafe and low-quality care. The COVID-19 pandemic has reinforced the need for all countries to be able to provide a standard of safe universal health coverage, acknowledging that “having access to health care is plainly not enough.”

4.1.1 WHO Patient Safety Friendly Hospital Initiative

In Pakistan, efforts are being made to put patient safety onto the national agenda through a series of interventions. A national framework and standards for patient safety and quality have been developed, providing a focal point for patient safety at the Ministry of Health. The Patient Safety Friendly Hospital Initiative (PSFHI) has also been implemented in 12 tertiary care hospitals, providing training to more than 300 hospital managers.

The PSFHI is intended to help institutions to develop patient safety programmes, with support from the World Health Organization. The PSFHI is a voluntary process whereby institutions undergo a process of assessment against international best practice standards. It involves a self-assessment exercise alongside guidance from experts, site visits and interviews across the following strategic areas:
·      Leadership commitment
·      Clear policies and guidelines
·      Competent and compassionate health professionals
·      Engaging patients and families
·      Using data to drive improvements.

Crucial to its implementation in Pakistan has been the support from the Ministry of Health and provincial health department, demonstrating the need for action through patient stories, and providing incentives and motivation in the form of certification.

The number of fragile, conflict- affected and vulnerable (FCV) settings has accelerated, with 50% of the global poor expected to live in these contexts by 2030. In addition, the damage caused by conflicts around the world have heavily impacted the development of health systems. It is imperative that health services are allowed to operate safely in these settings.

Set within this context of diminishing returns and widening disparities, this work explores the opportunities afforded from what are, in our view, two underutilised assets:

• Analysing what we know, and what we don’t know, from the publicly available global patient safety data, and
• Sharing examples of excellence (or ‘positive deviance’) from local teams who are measuring or improving safety in ways that utilise the unique perspectives and assets of patients, families and carers.

5.2 Data completeness

A significant proportion of the patient safety indicators (41%) are only available for High or Upper Middle-Income countries. Around a third of the indicators (32%) include data from East Asia and Pacific, Europe and Central Asia, and North America regions, which represents nearly three quarters (74%) of the world population.

Across many indicators, data is collected infrequently. For example, for one in six indicators, the most recent data is more than three years old. Of the 89 metrics we have selected for inclusion in the dashboard, no countries have all indicators populated. Australia, New Zealand and Norway are the countries with the highest availability of data with 75 populated indicators. The UK has 68 populated indicators. Changes in methods of data collection, and in the wording of some survey questions, makes comparisons and trend analysis challenging. Aside from recently piloted data by OECD, no new widely applicable patient safety indicators have been introduced for routine data collection in the past ten years.

Even looking at a subset of indicators, for a selection of comparable countries, differences in data completeness are stark. To illustrate this, we examined data completeness across OECD countries for 17 internationally recognised and collected indicators. These metrics were selected based on the following criteria:

• Internationally recognised and collected across a wide range of countries
• Closely linked to preventable harm
• Representative of different parts of the health system
• Aligned with the global patient safety movement towards a broader understanding of harm

The results are shown in Figure 3. Of the 17 metrics selected, only six are available for all OECD countries. Of these six, four are related to maternal and neonatal incidents. A key medication safety indicator (the proportion of the population who are chronic opioid users) is available for less than half of OECD countries.

At a country level (Figures 4 and 5 below), we see that only four countries report data on all 17 metrics. The UK reports data on 14 of the 17 – the three indicators missing are those related to medication safety. For the UK, and many other countries, data on these indicators are most likely available internally. Nevertheless, the lack of reporting at a global level represents a missed opportunity for benchmarking and shared learning. It is worth noting, however, that countries may be hesitant to report because they question the international comparability of some indicators. Improvements in coding practices and a nuanced approach to international comparisons are needed to reassure countries of the value of reporting at a global scale.

5.3 Data reliability

Even when indicators are reasonably well populated, there can remain challenges in determining whether lower rates of harm (or the contributors to harm) reflect better performance or poorer reporting. For example, for the Global Burden of Disease study to compile data on adverse effects of medical treatment, each eligible injury has to first be correctly documented and coded by each provider organisation within each country. Although each country is subject to the same methodology and process, variation is inevitable, and when this variation is unwarranted, it weakens confidence in the conclusions that can be drawn from the data.

Case study 3: Safety measurement and monitoring framework

The Safety measurement and monitoring framework (SMMF) resulted from a research study which sought to answer the question, how safe is care today? The framework identified five questions that are necessary to ask to give a complete picture of an organisation’s safety: Has patient care been safe in the past? Are our clinical systems and processes reliable? Is care safe today? Will care be safe in the future? Are we responding and improving?

Case study 4: Situational Awareness for Everyone (S.A.F.E.)

Situation Awareness For Everyone (SAFE) is a collaborative programme developed by the Royal College of Paediatrics and Child Health UK, enabling clinical teams to improve communication, build a safety culture and improve outcomes for children.

The concept behind the programme is that patient safety should be about managing risk, not simply about responding to incidents. SAFE involves teaching clinical teams in a practical, jargon-free way, supporting them to understand what they do well, what needs to improve, and how they can measure the impact of changes they make.

Only 10 (11.1%) of the 89 indicators are compiled from data reported directly by patients, families or carers, or by members of the public (two of which are part of a pilot programme of data collection). This is a notable deficit, given the unique insights that the users of services have on the safety of services, and the role that feeling safe has on the patient’s overall experience of care. However, innovative work is happening at a local level to build on these insights, and to ensure patients and families have the agency to use them to help keep themselves safe. An example of this work is at Cincinnati Children’s Hospital, where families are supported to identify signs of deterioration in children on the wards and use that to trigger a rapid, specialist clinical response (see case study 5 below).

Case study 5: Family-activated medical emergency teams

Rapid response systems, comprising tools to identify deteriorating patients (such as monitoring of physiological markers) and a multi-disciplinary team (typically based within ICUs) to respond to medical emergencies, have been shown to reduce arrests and deaths in children in hospital. Typically ‘activated’ by clinicians, a team at Cincinnati Children’s Hospital developed a model where the emergency response team could be triggered by the families of hospitalised children.

There are no indicators that relate to more strategic, policy or leadership aspects of patients safety, but it is welcome to see work underway from WHO to survey countries on their progress in these areas, following publication of the WHO Global Patient Safety Action Plan 2021-2030 (see table below).

5.4.1 Monitoring progress against the WHO Global Patient Safety Action Plan 2021-2030 (GPSAP)

The WHO GPSAP provides a framework for countries to develop their national plans for patient safety and will help to ensure a strategic and coordinated approach to patient safety at a global level. To help monitor progress against the seven strategic objectives in the GPSAP, and the implementation milestones within them, WHO surveyed member states throughout 2022 and early 2023 on the extent to which they have the necessary systems and processes in place to progress patient safety. This includes, for example, whether there exists a national policy or framework for patient safety, and whether there is an integrated educational curriculum for patient safety. The final report, to be produced in 2023, will provide key insights into progress of member states in developing the necessary leadership, strategic and infrastructural elements for the delivery of safe care.

WHO published an interim report in April 2023, compiled of responses from 102 countries across all six regions. Progress against achieving the core indicators from the WHO GPSAP were measured:
·      27% of countries have developed a national patient safety action plan or equivalent
·      36% of countries have implemented a system for reporting of never events
·      18% of countries have signed up for implementation of the WHO Health Worker Safety Charter
·      31% of countries have established national targets on reducing health care-associated infection rates
·      13% of countries have a patient representative on the governing board (or an equivalent mechanism in 60% or more hospitals).

The dashboard includes indicators that may not traditionally be associated with patient safety, such as timeliness or patient-centredness. Discussions abound in the literature about where the line should be drawn between safety and quality; however, there can be little doubt that how people experience and feel about their care can result in psychological harm, and delays in receiving treatment can result in physical impairment or premature death, both of which are safety-critical issues.

6. Insights from the data

This section includes some selected highlights, trends, and opportunities for meaningful comparisons from the data, for the purposes of learning from those countries and regions performing well on different aspects of patient safety. This is far from a comprehensive analysis – instead, users are encouraged to explore the dashboard for insights most relevant to you. Our analysis is organised into our patient safety country ranking, overall observations, areas of improvement and areas of concern.

6.1 Patient safety country ranking

Using the methodology outlined in Section 3.2, Norway is at the top of the ranking for patient safety. The UK ranks 21^st out of 38 countries, very close to the average across selected metrics, as shown in Figure 6.

In interpreting this ranking it is helpful to consider the following:

• Higher than average: The differences across the 23 countries that perform better than average are marginal – they are all within one standard deviation of the mean. The relative position of a country within this group should be considered with caution.
• Lower than average: Of the 15 countries that perform worse than average, only two (Colombia and Mexico) are beyond 1 standard deviation of the mean. The relative position of a country within the group of the remaining 13 countries should be considered with caution.

Additionally, this methodology has important limitations:

• The four indicators included only represent a small aspect of health system performance, with overrepresentation of maternal and newborn care. A more meaningful ranking would look at a broader range of indicators, but currently this is not possible because the data is not consistently reported.
• The indicators included only look at rates of deaths. The global patient safety movement has tried to move towards a broader understanding of harm including morbidity and psychological harm, but data across these other areas is still limited and inconsistently reported.

The patient safety movement has worked hard to encourage a cultural shift from blame to shared learning. We hope this ranking is a step in this direction, mobilising action and encouraging better data collection.

6.2 Overall observations

Two overall observations can be made by taking a high-level look at the global patient safety indicators:

• Many of the indicators show very little improvement in performance over time, often stretching back further than the data period under analysis in this report. In some cases, improvements in performance may be offset by improved reporting and data coding practices, but in others, this trend warrants further examination to better understand the causes. For example, there has been little overall improvement in performance on retained surgical item or device fragment – an area that has been subject to significant focus and improvement efforts in recent years (Figure 7).

• There is significant spread in performance, even between comparable groups of countries. Variation is, to some extent, to be expected between countries, allowing for contextual differences and the stage at which different countries may be on their patient safety journey. Significant variation between countries should act as a trigger for further enquiry, for example in the case of rates of maternal sepsis, Figure 8, to understand how much of the variation may be unwarranted – in other words, that which cannot be explained by, for example, population differences.

Our patient safety country ranking also highlighted the variation that exists across comparable countries. One way to illustrate the opportunities for improvement is to quantify deaths and DALYs (Disability-Adjusted Life Years) avoided if the UK performed at the level of the best performing decile of OECD countries. DALYs are defined as ‘the sum of years lost due to premature death (YLLs) and years lived with disability (YLDs). DALYs are also defined as years of healthy life lost’. In this instance they can help us to quantify the impact of death or disability from the adverse effects of medical treatment.

Using only the metrics included in the patient safety country ranking, we see that using the latest data available the UK could have had 17,356 fewer deaths and 15,835 fewer DALYs had it performed at the level of the top decile of OECD countries. Specifically:

• The UK had 48,482 deaths classified as treatable mortality in 2020. If the UK had matched the top decile this would have meant 15,773 fewer deaths.
• The UK had 1,484 deaths due to neonatal disorders in 2019. If the UK had matched the top decile this would have meant 776 fewer deaths.
• The UK had 34 maternal deaths in 2019. If the UK had matched the top decile this would have meant 27 fewer deaths.
• The UK had 1,266 deaths due to adverse effects of medical treatment in 2019. If the UK had matched the top decile this would have meant 780 fewer deaths.
• The UK had 25,883 DALYs due to adverse effects of medical treatment in 2019. If the UK had matched the top decile this would have meant 15,835 fewer DALYs.

6.4.6 Staff and patient perceptions of safety

Perceptions of safe care, whether reported by staff or patients, is an important source of insight about the extent to which unacceptable risks exist within care systems and processes. While several regional or country level systems are in place to gather this important source of process data, very little data exists at a standardised, international level.

The OECD has recently piloted some measures, examining health worker perceptions of handoffs and transitions, safety culture, and overall perceptions of safety, and patients experiencing a medical or medication-related mistake. These are excellent examples of leading indicators, that, when used appropriately, can help to identify risks before they result in poor outcomes for patients. Patient perceptions of safety and risk, including at the point of discharge from hospital, have also been developed at a local level (see case studies 8 and 9).

Case study 8: Patient measure of safety

Figure 24 illustrates significant variation across the participating countries for patients reporting a medical mistake during their treatment, while Figure 25 reports differences in health worker perceptions of handoffs and transitions and overall perceptions of safety. Both indicators offer valuable opportunities for countries to learn from what others are doing well in these areas.

Case study 9: Partners at care transitions measure

The Partners at Care Transitions Measure (PACT-M) is a patient-reported questionnaire to assess the quality and safety of care transitions from hospital to home for older patients (over 65 years old). The measure has been adopted by teams around the world, including in Denmark, China, Sweden and Bahrain, primarily for research or service evaluation purposes.

7. Conclusions and recommendations

Several insights can be drawn from our interviews with people who have developed innovative, patient-driven ways to measure and improve patient safety. First, patients, families, and carers offer insights into safe and unsafe care that cannot be obtained from existing sources – in the words of one interviewee, this is “novel not redundant information”. Second, patients, families and carers need to be empowered and encouraged by staff, and the wider system, to take a more positive and proactive role in patient safety – simply creating the opportunities alone is unlikely to be sufficient. Third, to ensure more widespread and effective adoption of patient, family and carer led improvement interventions, the practical steps involved need to be systematically recorded and shared – publishing findings in research papers is not the only route to achieving this.

In our 2022 report, we made several recommendations, including the need to increase the breadth of patient safety data collected at a national level. The report states:

Based on our analysis for this report, similar deficits in the global patient safety data can be observed. If data are to be used for understanding the current state of patient safety, for targeting improvement efforts, and for assessing the impact of these efforts, they need to better reflect the care journeys, perceptions, and experiences of patients – particularly for those patients who are our most vulnerable or disadvantaged members of society.

Our patient safety country ranking highlights existing variations in performance and clear opportunities for shared international learning. Nevertheless, better reporting is vital. Due to variations in reporting, currently a country with a strong incident reporting culture may have a higher number of patient safety incidents and hence appear lower in the ranking. It is imperative that improved data collection efforts are accompanied by a patient safety culture shift to address this.

Recent work by Vincent and Marang-van de Mheen (2023) challenges us to give less attention to the merits of individual indicators, and more consideration to the criteria and desirable characteristics of sets of indicators:

The authors pose a series of questions that ought to be addressed to shape and refine an indicator set, including: Who will be using it? What questions does it need to answer? How many indicators are needed? Will it have any unintended consequences? Most fundamental of all, the authors ask, what is the underlying construct?

In the context of a global indicator set for patient safety, and supporting 2023’s theme for World Patient Safety Day, this must now include consideration of the patient’s perspective of patient safety, their trajectory of care through complex health care systems, and any inequities in safe care on account of their demographic characteristics or socio-economic circumstances. Alongside the introduction of measures that offer insight into the fundamental components of a safe health care system, and other vital cultural measures, it should be possible in future to better understand the global state of patient safety.

Based on these conclusions, we make the following recommendations:

1. Assessment: A more balanced and comprehensive set of global patient safety indicators is required to address the data gaps identified in this report, and to ensure comparable data is available for countries across all income levels. Consensus is required on the minimum set of indicators that all countries should report on. This work should involve key stakeholders including WHO, Ministries of Health, expert bodies, people with lived experience, and healthcare workers. The Ministerial Summits have highlighted the need for sustained and supported implementation of initiatives. National and civic leaders should support their systems, providers and frontline teams to ensure the data provided is as accurate and complete as possible.
2. Adoption: A global repository of safety measurement and improvement interventions should be developed. Interventions should be recorded and uploaded using a common reporting framework, such as an adapted version of the TIDieR framework, to ensure consistency and support their effective adoption. Healthcare workers and researchers should be supported and encouraged to report their interventions to the repository as a matter of routine. This repository should be freely available to decision-makers at the health system, hospital and practice level, with the ability for each to action as relevant to their specific context.
3. Activation: The adoption of patient-driven safety measurement and improvement interventions, including those featured in this report, must be accelerated. To ensure the faithful adoption of interventions, patients, families and carers must be given the agency to become active and equal partners in the delivery of safe care.  Leaders within healthcare organisations must therefore ensure there is a culture of patient and family involvement across all safety improvement efforts.

Acknowledgements

This report was produced by Imperial College London's Institute of Global Health Innovation. It was made possible by the generosity of the charity Patient Safety Watch founded by the Rt Hon Jeremy Hunt MP, chaired by James Titcombe OBE.

The authors would like to thank the following people who have provided valuable input and advice in the production of this report: Niek Klazinga, Mike Durkin, Bryony Dean Franklin and Paul Aylin.

Special thanks go to the practitioners, advocates and experts who kindly gave their time to be interviewed for this work: Pat Brady, Christina Davidson, Peter Lachman, Rebecca Lawton, Anne MacLaurin, Afifa Munawar, Jane O’Hara, Deborah Prowse, Shin Ushiro and Jo Wailing.

Thank you to the team within the Institute of Global Health Innovation who reviewed and supported the production of the report: Amish Acharya, Sarra Khadir, Emily Medcalf, Victoria Murphy and Brittany Rae.

The authors received infrastructure support from the NIHR North West London Patient Safety Research Collaboration. Patient Safety Watch would like to thank Joe Kiani for Masimo Foundation’s financial support.

Suggested Citation

Illingworth J, Shaw A,  Fernandez Crespo R, Leis M, Fontana G, Howitt P, Darzi A. Global State of Patient Safety 2023. Imperial College London (2023).