Our landing page for this Spotlight lists some causes of harm as follows:
1. Medication errors. Medication-related harm affects 1 out of every 30 patients in health care, with more than a quarter of this harm regarded as severe or life threatening.
2. Surgical errors. Harm may occur before, during or after surgery. Most unsafe surgical care arises not from dramatic errors, but from small system failures — missed checks, poor communication, and inadequate monitoring — that accumulate into avoidable harm.
3. Health care-associated infections. Hand hygiene, failure of aseptic technique, poor sterilisation of instruments, inadequate environmental cleaning...
4. Diagnostic errors. These occur in 5–20% of physician–patient encounters.
5. Incorrect treatments.
6. Patient misidentification
7. Unsafe injection practices
In our discussion we have emphasised another pervasive cause of harm, namely a lack of clinical knowledge and lack of access to reliable healthcare information. We have also noted the importance of factors such as an overburdened, exhauste workforce.
Indeed, any practice environment, setting, or facility that does not meet the basic needs of a healthcare provider to deliver effective care can be described as 'unsafe'.
One point that we have not learned in this discussion is the relative contribution of all the above to unsafe care.
The only pointer I have noted is the WHO fact sheet that states that around 50% of preventable errors are medication errors.
The list of seven above is typical of what the patient safety movement have traditionally focused on. Charles Vincent and others have since shown that unsafe care is primarily due to health systems factors rather then isolated errors.
I would like to suggest that future research on patient safety could look more closely at the contribution of a failure to meet the basic needs of healthcare providers.
On HIFA we have described these with the acronym SEISMIC
• Skills
• Equipment
• Information
• Systems
• Medicines
• Incentives
• Communication facilities.
This inevitably widens the scope from unsafe care to poor-quality care. That said, I remain sceptical about the difference. For me, if I am a patient and I receive poor quality care, this by definition is unsafe. If I receive poor care and I die as a result, this is undeniably 'unsafe' in which case around 5 million people die every year due to unsafe care and not 3 million as widely reported.
As we have stated the figure of 5 million is almost certainly a gross underestimate because it does not include care in home and community (author communication). The paper from which this 5m comes has a glaring gap which has not yet been filled. It gives estimates of deaths from poor quality care but is unable to analyse the quantitative contributions of different deteminants.
Kruk M, Gage A, Joseph N et al.
Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries
The Lancet, 2018; 392, 2203-2212
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31668-4/fulltext
For example, we do not know to what extent the seven causes listed above may have contributed, nor do we know to what extent lack of access to reliable healthcare information contributed.
Data on this is very scarce. One approach is through social autopsy. Merlin Wilcox and colleagues wrote a paper 'Care pathways during a child's final illness in rural South Africa: Findings from a social autopsy study.' 2019. They concluded: 'Modifiable factors for preventing deaths during a child's final illness occur both inside and outside the home. The most important modifiable factors occuring inside the home relate to caregivers' recognition of illness and appreciation of urgency in response to the severity of the child's symptoms and signs. Outside the home, modifiable factors relate to inadequate referral and follow-up by health professionals. Further research should focus on identifying and overcoming barriers to referral.' https://www.repository.cam.ac.uk/items/8b6b90bf-3c64-440c-84f3-d2c64208995e
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org