Global patient safety report 2024

Globalpatientsafetyreport2024 Globalpatientsafetyreport2024 Globalpatientsafetyreport2024 ISBN978-92-4-009545-8(electronicversion)ISBN978-92-4-009546-5(printversion) ©WorldHealthOrganization2024 Somerightsreserved.ThisworkisavailableundertheCreativeCommonsAttribution-NonCommercial-ShareAlike 3.0IGOlicence(CCBY-NC-SA3.0IGO;https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Underthetermsofthislicence,youmaycopy,redistributeandadapttheworkfornon-commercialpurposes,providedtheworkisappropriatelycited,asindicatedbelow.Inanyuseofthiswork,thereshouldbenosuggestionthatWHOendorsesanyspecificorganization,productsorservices.TheuseoftheWHOlogoisnotpermitted.Ifyouadaptthework,thenyoumustlicenseyourworkunderthesameorequivalentCreativeCommonslicence.Ifyoucreateatranslationofthiswork,youshouldaddthefollowingdisclaimeralongwiththesuggestedcitation:“ThistranslationwasnotcreatedbytheWorldHealthOrganization(WHO).WHOisnotresponsibleforthecontentoraccuracyofthistranslation.TheoriginalEnglisheditionshallbethebindingandauthenticedition”. AnymediationrelatingtodisputesarisingunderthelicenceshallbeconductedinaccordancewiththemediationrulesoftheWorldIntellectualPropertyOrganization(http://www.wipo.int/amc/en/mediation/rules/). Suggestedcitation.Globalpatientsafetyreport2024.Geneva:WorldHealthOrganization;2024.Licence:CCBY-NC-SA3.0IGO. Cataloguing-in-Publication(CIP)data.CIPdataareavailableathttps://iris.who.int/. Sales,rightsandlicensing.TopurchaseWHOpublications,seehttps://www.who.int/publications/book-orders.Tosubmitrequestsforcommercialuseandqueriesonrightsandlicensing,seehttps://www.who.int/copyright. Third-partymaterials.Ifyouwishtoreusematerialfromthisworkthatisattributedtoathirdparty,suchastables,figuresorimages,itisyourresponsibilitytodeterminewhetherpermissionisneededforthatreuseandtoobtainpermissionfromthecopyrightholder.Theriskofclaimsresultingfrominfringementofanythird-party-ownedcomponentintheworkrestssolelywiththeuser. Generaldisclaimers.ThedesignationsemployedandthepresentationofthematerialinthispublicationdonotimplytheexpressionofanyopinionwhatsoeveronthepartofWHOconcerningthelegalstatusofanycountry,territory,cityorareaorofitsauthorities,orconcerningthedelimitationofitsfrontiersorboundaries.Dottedanddashedlinesonmapsrepresentapproximateborderlinesforwhichtheremaynotyetbefullagreement. Thementionofspecificcompaniesorofcertainmanufacturers’productsdoesnotimplythattheyareendorsedorrecommendedbyWHOinpreferencetoothersofasimilarnaturethatarenotmentioned.Errorsandomissionsexcepted,thenamesofproprietaryproductsaredistinguishedbyinitialcapitalletters. AllreasonableprecautionshavebeentakenbyWHOtoverifytheinformationcontainedinthispublication.However,thepublishedmaterialisbeingdistributedwithoutwarrantyofanykind,eitherexpressedorimplied.Theresponsibilityfortheinterpretationanduseofthemateriallieswiththereader.InnoeventshallWHObeliablefordamagesarisingfromitsuse. Design:MacroGraphicsPvt.Ltd. Contents Foreword—DrTedrosAdhanomGhebreyesus vii Foreword—SirLiamDonaldson viii Foreword—DrBruceAylward x Preface—DrNeelamDhingra xii Preface—DrRudiEggers xiv Acknowledgements xv Abbreviations xix Glossaryofterms xxi Executivesummary xxvii Introduction 1 Burdenofharminhealthcare 11 Burdenofharmtothepatients 14 Geographicdistributionofharminhealthcare 14 Burdenofharmbydemographicdistribution 15 Burdenofharmbymedicalsettingandclinicaldomain 17 Burdenofharmbysource 21 Measurementconsiderationsandconclusions 25 Financialandeconomicburdenofunsafecare 27 Thedirectcostsunsafecareimposesonhealthcaresystemsandbudgets 28 Directcostsbysettingandsourceofharm 29 Indirectcostsofunsafecare 31 Strategicobjective1.Policiestoeliminateavoidableharminhealthcare 35 Strategy1.1.Patientsafetypolicy,strategyandimplementationframework 41 Patientsafetyasapriorityinnationalhealthpolicy 41 IntegrationofpatientsafetyinUHCservicedeliverypackages 43 Patientsafetypolicyandstrategy 44 Nationalpatientsafetyactionplan 45 Nationalpatientsafetyprogramme 45 Strategy1.2.Resourcemobilizationandallocation 50 Budgetcategoryandallocationoffinancialresources 50 Humanresourceplanandgapclosure 51 Recognitionandrewardmechanisms 52 Strategy1.3.Protectivelegislativemeasures 54 Mandatorylicensingforhealthcarefacilitiesandservices 54 Lawsforauthorizationofmedicalproducts 55 Legalprotectionagainstreportingofpatientsafetyincidents 56 Dataprotectionandconfidentiality 57 Strategy1.4.Safetystandards,regulationandaccreditation61 Minimumsafetystandards61 Safetystandardsinhealthcarelicensing62 Safetystandardsforallspecifiedclinicalservices63 Safetystandardsinhealthservicesassessmenttools64 Voluntaryaccreditationprogrammesandsafetystandards65 Strategy1.5.WorldPatientSafetyDayandGlobalPatientSafetyChallenges67 WorldPatientSafetyDay67 WHOGlobalPatientSafetyChallenges70 Strategicobjective2.High-reliabilitysystems75 Strategy2.1.Transparency,opennessandnoblameculture82 Safetycultureimplementation83 Neverand/orsentineleventsreporting84 Noblamepolicyandjustculture85 Strategy2.2.Goodgovernancefor