The World Health Organization (WHO) maintains a pivotal role in improving and promoting world health and has done so since its establishment in 1948. Like most organisations it has had its share of successes and failures. It remains, however, a champion of global health improvement and patient safety and is rightly highly valued.
The WHO has been heavily criticised by US President Donald Trump on its handling of the COVID-19 pandemic (Bennett, 2020). Gostin and Kavanagh (2020) accept that there are valid criticisms of the WHO, but claim that many made recently are simply wrong.
WHO and global patient safety
The WHO's work in global patient safety has had a direct influence on NHS efforts to develop an ingrained patient safety culture. Some useful materials and initiatives have been developed. In developing home-grown NHS patient safety initiatives, it is always useful for policy makers and developers to look outside the NHS and to consider comparative perspectives. It is important not to reinvent the patient safety wheel.
The WHO patient safety mission (WHO, 2020a) is stated as follows:
‘The mission of WHO patient safety is to coordinate, facilitate and accelerate patient safety improvements around the world by being a leader and advocating for change; generating and sharing knowledge and expertise; supporting member states in their implementation of patient safety actions.’
WHO patient safety initiatives
The WHO has delivered several important initiatives on patient safety, which include publications, training, education, campaigns, tools and conferences. Global activity on patient safety has included the Multi-Professional Patient Safety Curriculum Guide (WHO, 2011), the Surgical Safety Checklist (WHO, 2009), and Medication without harm: the WHO global patient safety challenge (WHO, 2017).
Global collaboration
The WHO and the UK Government have entered into a new strategic collaboration towards establishment of the Global Patient Safety Collaborative (GPSC) (WHO, 2020b):
‘The Global Patient Safety Collaborative will enable countries to collaborate at global, regional and national levels to focus on patient safety as one of the most important components of health care delivery.’
World Patient Safety Day
The first-ever World Patient Safety Day was held on 17 September 2019. This will now be an annual event and is designed to create awareness of patient safety. The WHO's director general Dr Tedros Adhanom Ghebreyesus (2019) stated the need for the global imperative behind this event:
‘No one should be harmed while receiving health care. And yet globally, at least 5 patients die every minute because of unsafe care. We need a patient safety culture that promotes partnership with patients, encourages reporting and learning from errors, and creates a blame-free environment where health workers are empowered and trained to reduce errors.’
WHO initiatives in the NHS
WHO patient safety activity has filtered into the NHS and there are many examples of collaborations. The NHS is also a leading contributor to WHO patient safety initiatives.
Surgical safety
An example of how WHO patient safety work has positively influenced NHS clinical practice is the Surgical Safety Checklist (WHO, 2009).
It is clear that just by itself the checklist is not enough to change NHS patient safety culture. To make healthcare safer, much more needs to be done and added.
Many policies and tools and guidelines have been issued, but patient safety problems persist. These guidelines include the National Safety Standards for Invasive Procedures (NatSSIPs) (NHS England, 2015) and ‘Never Events’ (NHS England and NHS Improvement, 2020).
According to the WHO (2020c) the reported crude mortality rate after major surgery is 0.5–5% and after inpatient operations, complications occur in up to 25% of patients. In industrialised countries, nearly half of all adverse events in hospitalised patients are related to surgical care. The WHO state that at least half of the cases in which surgery led to harm are considered preventable.
NHS Resolution
NHS Resolution recently analysed surgical burns, litigation and patient safety and stated:
‘From 1 April 2009 to 31 March 2019, NHS Resolution were notified of 631 clinical negligence claims relating to surgical burns to patients. Out of these 631 claims, 459 were settled, 58 were unmeritorious and 114 are still open. This has led to NHS Resolution paying £13.9m in damages and legal costs on behalf of NHS organisations.’
Surgery remains a significant area of NHS clinical negligence liability. The WHO (2009) checklist steps are listed under the following headings: before induction of anaesthesia, before skin incision, and before patient leaves operating room. This checklist is not intended to be comprehensive and additions to fit local practice are encouraged.
NatSSIPs
There is a discussion of the WHO (2009) checklist in the introduction to NatSSIPs (NHS England, 2015):
‘The introduction of the WHO Safer Surgery Checklist was a great step forward in the delivery of safer care for patients undergoing operations. Experience with its use has suggested that the benefits of a checklist approach can be extended beyond surgery towards all invasive procedures performed in hospitals.’
The point is emphasised that safety is more than simply having checklists:
‘Safety is not just about checklists, teamwork or human factors, it is about checklists AND teamwork AND human factors—and many other things beside.’
Never Events
In order to reduce the incidence of ‘Never Events’, the NHS has both the WHO (2009) and NHS England (2015) guidance and many other guidelines and policies. However, all this is not enough to stem the rise of Never Events in the NHS. In its seminal report, Opening the Door to Change, the Care Quality Commission (CQC) (2018) stated:
‘What sets Never Events apart is that they are believed to be wholly preventable by the implementation of the appropriate safety protocols. Despite this preventability, the number of Never Events has not fallen. About 500 times each year we are not preventing the preventable.’
A look at some Never Events between 1 April 2019 and 29 February 2020, compound the severity of the patient safety problem in the NHS. NHS England and NHS Improvement (2020) state that 218 Never Events took place for wrong site surgery and these include:
Incidences of retained foreign object post-procedure numbered 90 and included:
Such Never Events shows deep-rooted patient safety problems exist in the NHS.
CQC proposals
The CQC (2018) noted several endemic patient safety problems around Never Events and more generally in the NHS:
‘Staff are struggling to cope with large volumes of safety guidance, they have little time and space to implement guidance effectively, and the systems and processes around them are not always supportive.’
In terms of the NHS patient safety landscape, the CQC (2018) stated that there is a lot of confusion about the roles of different bodies and where trusts can go to get the most appropriate support. There is no clear system for staff to learn from each other at a national level. Local reporting systems are often poor quality and do not support staff well.
The CQC (2018) makes a number of recommendations, which include that NHS Improvement should work in partnership with Health Education England and others to make sure that the entire NHS workforce has a common understanding of patient safety and the skills and behaviours and leadership culture necessary to make it a priority.
The NHS Patient Strategy (NHS England and NHS Improvement, 2019) has the potential to work through the issues of global and national patient safety policy information and guidance overflow and to help cascade this information properly through the NHS.
Conclusion
The patient safety work of the WHO has made a positive contribution to developing a safer NHS. Patient safety tools and checklists by themselves, however, are not enough to deal with the endemic problems. The persistent NHS patient safety problem of ‘Never Events’ in surgery shows the complex nature and interplay of the problems and issues involved.
There is also the danger of saturating and confusing NHS staff with too much patient safety and health quality guidance, a problem that needs to be properly addressed. The new NHS Patient Safety Strategy is a promising start towards doing this.