final-draft-global-patient-safety-action-plan-2021-2030.pdf

Draft Global Patient Safety Action Plan 2021–2030 Towards eliminating avoidable harm in health care Contents 1. Introduction......................................................................................................................................................................................................1 1.1 Background...........................................................................................................................................................................................1 1.1.1 Emergence of patient safety thinking.............................................................................................................................2 1.1.2 Global burden of unsafe care.............................................................................................................................................2 1.1.3 Evolution of the global patient safety movement......................................................................................................3 1.1.4 Coronavirus disease (COVID-19): a broader concept of avoidable harm...........................................................5 1.2 Mandate.................................................................................................................................................................................................5 1.3 Development process.......................................................................................................................................................................6 2. Vision, mission and goal...............................................................................................................................................................................8 3. Guiding principles..........................................................................................................................................................................................9 3.1 Engage patients and families as partners in safe care..........................................................................................................9 3.2 Achieve results through collaborative working......................................................................................................................9 3.3 Analyse and share data to generate learning..........................................................................................................................9 3.4 Translate evidence into actionable and measurable improvement............................................................................. 10 3.5 Base policies and action on the nature of the care setting.............................................................................................. 10 3.6 Use both scientific expertise and patient experience to improve safety.................................................................... 10 3.7 Instil a safety culture in the design and delivery of health care..................................................................................... 10 4. Partners in action......................................................................................................................................................................................... 11 4.1 Governments.................................................................................................................................................................................... 11 4.2 Health care facilities and services.............................................................................................................................................. 11 4.3 Stakeholders...................................................................................................................................................................................... 12 4.4 The WHO Secretariat...................................................................................................................................................................... 12 5. Framework for action................................................................................................................................................................................. 13 Strategic objective 1. Policies to eliminate avoidable harm in health care............................................................................. 16 Strategic objective 2. High-reliability systems.................................................................................................................................. 23 Strategic objective 3. Safety of clinical processes............................................................................................................................ 31 Strategic objective 4. Patient and family engagement.................................................................................................................. 40 Contents | iii Strategic objective 5. Health worker education, skills and safety.............................................................................................. 48 Strategic objective 6. Information, research and risk management.......................................................................................... 54 Strategic objective 7. Synergy, partnership and solidarity........................................................................................................... 63 6. Implementation............................................................................................................................................................................................ 69 6.1 Policy options for implementation of the global action plan......................................................................................... 69 6.2 Key milestones in implementing the global action plan.................................................................................................. 69 7. Monitoring and reporting......................................................................................................................................................................... 73 7.1 Core Indicators.................................................................................................................................................................................. 73 7.2 Advanced indicators....................................................................................................................................................................... 77 8. Alignment of patient safety with the United Nations Sustainable Development Goals................................................... 79 9. Mapping World Health Assembly resolution WHA72.6 with the Global Patient Safety Action Plan 2021–2030...... 83 10. Acknowledgements.................................................................................................................................................................................... 88 11. Bibliography................................................................................................................................................................................................... 90 iv | Draft Global Patient Safety Action Plan 2021–2030 Overview of the Global Patient Safety Action Plan 2021–2030 Vision A world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere Governments Stakeholders Health care facilities and services World Health Organization Mission Drive forward policies, strategies and actions, based on science, patient experience, system design and partnerships, to eliminate all sources of avoidable risk and harm to patients and health workers Goal Achieve the maximum possible reduction in avoidable harm due to unsafe health care globally Patients and families as partners Evidence into improvement Results through collaboration Policies and action Data to generate learning Scientific expertise and Safety culture patient experience High-reliability Patient and family Information, research systems engagement and risk Health management Policies Safety worker Synergy, to eliminate of clinical avoidable education, skills partnership processes and safety and solidarity harm Overview of the Global Patient Safety Action Plan 2021–2030 | v 1. Introduction O ver the next 10 years, the World Health Organization (WHO), its global partners and its Member States will be working tirelessly to help all people of the world to movement. Through its year-by-year milestones, this flagship initiative will be the driver for the successful implementation of the global action plan. have access to health services. The global action plan, set out in this document, will Universal health coverage is an inspiring goal whereby provide a strategic direction for concrete actions to be all individuals and communities receive safe and quality taken by countries, partner organizations, health care health services without suffering financial hardship. This facilities and WHO to implement World Health Assembly is the target to be achieved if the world is to stay on track resolution WHA72.6. As a result, it will strengthen health to achieve the United Nations Sustainable Development systems globally to diagnose, treat, cure, and care, whilst Goals (SDGs) and the “triple billion” goals in the WHO striving to “first, do no harm” the celebrated maxim of the Thirteenth General Programme of Work. However, the Greek physician, Hippocrates (460–375 BC). sustainable development agenda will not be met without ensuring that health services are safe. In the absence of such assurance, the benefits of increased coverage cannot 1.1 Background be fully realized, and people may experience reduced trust Every point in the process of care can contain an inherent in health services and reduced willingness to seek health risk. The nature and scale of risks vary greatly, based on care – even when they most need it. the context of health care provision and its availability, That is why the Seventy-second World Health Assembly infrastructure and resourcing within and across countries. in May 2019 adopted resolution WHA72.6 on “Global The challenge for all health systems and all organizations action on patient safety” to give priority to patient safety providing health care is to maintain a heightened as an essential foundational step in building, designing, awareness to detect safety risks, as well as to address all operating and evaluating the performance of all health sources of potential harm. care systems. The adoption of this resolution was a Patient safety is a framework of organized activities remarkable milestone in global efforts to take concerted that creates cultures, processes, procedures, behaviours, action on patient safety and reduce the burden of patient technologies and environments in health care that harm due to unsafe health care. consistently and sustainably lower risks, reduce the The resolution requested the Director-General of occurrence of avoidable harm, make error less likely and WHO to formulate a global patient safety action plan reduce impact of harm when it does occur. in consultation with Member States and a wide range The practice of patient safety involves coordinated action of partners and other organizations. To respond to to prevent harm to patients, caused by the processes of resolution WHA72.6 and move forward from global health care themselves. commitment to tangible action, WHO launched a flagship initiative in February 2020: "A Decade of Patient safety is a strategic priority for modern health Patient Safety 2020–2030". This important step defines care and is central to countries’ efforts in working towards WHO’s contribution to the global patient safety universal health coverage. Introduction | 1 As a theme of scholarship and research, patient safety The paradigm shift in thinking about safety in health draws on the concepts and methods of many disciplines, care came with the realization that it was not completely including health services research, applied psychology, different from other high-risk industries, and when behavioural science, ergonomics, communication science, things went wrong it was seldom due to an error by a accident theory and systems research. single individual. Rather, the true cause of an accident in aviation or an adverse event in health care was often 1.1.1 Emergence of patient safety human error embedded in a complex amalgam of actions and interactions, processes, team relationships, thinking communications, human behaviour, technology, organizational culture, rules and policies, as well as the In the period immediately after the Second World War, nature of the operating environment. With this realization when many countries were developing their health care came a deeper understanding that the poor design and systems, the idea of safety was limited to traditional operation of systems could provoke human error or hazards such as fire, equipment failure, patient falls worsen its impact when it occurred (1). and the risk of infection. There was also a belief that health workers, such as well-trained staff (that is, In this systems thinking view of the risks of health doctors and nurses), would always behave carefully and care, the term “medical error” became something of conscientiously and seek to avoid or minimize what were a misnomer, since error in itself was not the primary seen as inevitable “complications” of care. At that time, problem. Indeed, harm to patients cannot be corrected postoperative bleeding, fetal distress during childbirth solely by urging health workers to be more careful. The and wound infections were – and still remain – consistent use of the term “patient safety”, a more holistic concept, to harms or complications associated with care. There are describe the safety risks in health care and the measures many more. to address these risks and patient harm came into being at the beginning of the 21st century (2). It recognized Similarly, there have long been events in health care the scale of the problem of inadvertent harm in the considered as unexpected complications – for example, delivery of health care, the common causes that allowed transfusion of the wrong blood group, administration of similar kinds of adverse events to occur in all countries too high a dose of medication for a child, carrying out a worldwide, the need to see human error as something surgical procedure on the wrong side of the body, and to be mitigated and prevented rather than eliminated many more, sometimes resulting in the death of patients. entirely, and the strong parallels with the experience of For most of the 20th century, whilst such occurrences other high-risk industries, thus creating opportunities would occasionally hit the headlines, cause momentary for transfer learning. An alternative emerging approach public concern, and be a preoccupation of medical in patient safety (Patient Safety II) focuses on proactively litigation lawyers, they aroused little interest amongst making health care safer through an emphasis on the doctors and health care leaders. Why? Essentially, they conditions under which people succeed rather than fail. were seen as the inevitable cost of doing business in the This perspective views patient safety in terms of intended pressurized, fast-moving environment of modern health and acceptable outcomes to the extent possible. care that was saving lives and successfully treating many more diseases. Mistakes happen, it was argued. They were also viewed mainly as local events best dealt with through internal investigation. 1.1.2 Global burden of unsafe care Studies in the 1990s began to view the safety of care The magnitude of the problem of unsafe care attracted through a different lens. They showed that the frequency greater public attention with the release of the landmark of adverse outcomes amongst hospital patients was report To err is human: building a safer health system, substantial and had hitherto been little recognized. published by the United States Institute of Medicine in They introduced the term “medical error” to describe this 1999 (3). The report extrapolated a death rate from the phenomenon, and it became widely adopted by policy- incidence of adverse events in United States hospitals makers, researchers, clinicians, patient groups and the from two earlier studies and estimated that at least media. Other terms also came into common usage to 44 000 and perhaps as many as 98 000 people died in describe safety failures in health care, such as incident, hospitals each year as a result of medical errors. In 2000, adverse event, serious untoward incident, never event, the United Kingdom Department of Health published An near miss and close call. organisation with a memory (4). Both reports scoped the 2 | Draft Global Patient Safety Action Plan 2021–2030 subject of safety and harm in health care, drew parallels (OECD). This is in addition to the 15% of acute care activity with other high-risk industries, and provided the first caused by harm occurring in hospitals alone (6). estimates of the burden of patient harm for what was to become a new health priority and a new field of research According to recent estimates, the social cost of patient in health services. harm can be valued at US$ 1 trillion to 2 trillion a year. A human capital approach suggests that eliminating In more recent years, the focus has also been on economic harm could boost global economic growth by over 0.7% losses and access problems due to unsafe care that have annually (13). the potential to become major barriers to achieving universal health coverage (5). Research studies have 1.1.3 Evolution of the global patient shown that an average of one in 10 patients is subject to an adverse event while receiving hospital care in high- safety movement income countries (6). The estimate for low- and middle- In May 2002, the Fifty-fifth World Health Assembly income countries suggests that up to one in four patients adopted resolution WHA55.18. This urged Member States is harmed, with 134 million adverse events occurring to pay the closest possible attention to the problem of annually due to unsafe care in hospitals, contributing to patient safety and to establish and strengthen evidence- around 2.6 million deaths (7). Overall, 60% of deaths in low- based systems necessary for improving patient safety and and middle-income countries from conditions amenable the quality of health care. to health care are due to unsafe and poor-quality care (8). People mostly link patient safety with hospital-based care; however, unsafe care is a systemwide problem. Half World Alliance for Patient Safety of the global disease burden arising from patient harm (2004–2014) originates in primary and ambulatory care (9). Subsequently, in May 2004, the Fifty-seventh World Health The economic cost of unsafe care can be understood in Assembly supported the creation of an international two ways: the direct cost due to resource wastage and the alliance to facilitate the development of patient safety indirect costs in loss of productivity in the population. In policy and practice in all Member States and to act as a high-income countries, up to 15% of hospital expenditure major force for improvement globally. In October 2004, can be attributed to wastage due to safety failures. For the World Alliance for Patient Safety was launched as a example, the National Health Service in England paid working partnership between WHO and external experts, £1.63 billion in litigation costs because of safety lapses in health care leaders and professional bodies. The creation 2017–2018 (10). of the World Alliance for Patient Safety was a hugely significant step in the struggle to improve the safety of Unsafe medication practices and errors – such as health care in all Member States. Working in partnership incorrect dosages or infusions, unclear instructions, use of with WHO, the World Alliance for Patient Safety took abbreviations and inappropriate or illegible prescriptions – on this mantle and a programme of work was rapidly are a leading cause of avoidable harm in health care initiated, backed by a substantial allocation of foundation worldwide. Globally, the cost associated with medication funding from the United Kingdom Government (14). errors has been estimated at US$ 42 billion annually (11), not counting lost wages and productivity or increased The World Alliance for Patient Safety created a unique health care costs. This represents almost 1% of global environment in which major new initiatives arose that expenditure on health. Unsafe and poor-quality care leads individual partners were not able or willing to undertake to US$ 1.4 trillion to 1.6 trillion worth of lost productivity alone. It became a vehicle for sharing knowledge and each year in low- and middle-income countries.2 resources aimed at improving the safety of health care. It was envisaged that patient safety solutions, identified and Available evidence estimates the direct costs of harm, evaluated by one or two health systems or major hospital such as additional tests, treatments and health care, in the groups, would be adapted for global or multi-country primary and ambulatory setting to be around 2.5% of total implementation. It was also foreseen that additional health expenditure, though this probably underestimates coordination and facilitation of international expertise the true figure (12). Harm in primary and ambulatory care and learning would reduce duplication of efforts and often results in hospitalizations. Each year, these may minimize the wastage of valuable resources. account for over 6% of hospital bed-days and more than 7 million admissions among member countries of the A fundamental aim of the World Alliance for Patient Safety Organisation for Economic Co-operation and Development was to facilitate the development of patient safety policy Introduction | 3 and practices in Member States. It was planned that Patient Safety Solutions programme to identify, this would be accomplished through the fulfilment of a develop and promote worldwide interventions to number of core functions and other short-term initiatives improve patient safety; as set out by the World Alliance for Patient Safety in an Reporting and Learning best practice guidelines to annual work programme. aid in the design and development of existing and new incident reporting systems; Global Patient Safety Challenges Patient Safety Curriculum guides (in two editions: the first for medical schools, followed by a multi- The first programme of work produced by the World professional edition) to assist in patient safety Alliance for Patient Safety introduced the concept of the education in universities, schools and professional Global Patient Safety Challenge. This initiative identifies a institutions in the fields of dentistry, medicine, patient safety burden that poses a significant risk to health, midwifery, nursing and pharmacy; then develops front-line interventions and partnerships with countries to disseminate and implement the African Partnerships for Patient Safety, for building interventions. Each Challenge focuses on a topic that poses sustainable hospital-to-hospital patient safety a major and significant risk for patient health and safety. partnerships. The topic chosen for the first Global Patient Safety Challenge in 2005 was health care-associated infections WHO Patient Safety Initiatives Clean Care is Safer Care (15). This topic became a key (2015–2020) element of WHO’s early work was followed a few years later by Safe Surgery Saves Lives, the second Global In 2016, a WHO Global Consultation on Setting Patient Safety Challenge (16). Both Global Challenges Priorities for Global Patient Safety provided a platform aimed to gain worldwide commitment and spark action to recognize that the scale of avoidable harm in health to reduce health care-associated infections and the risks care systems around the world was unacceptably high, associated with surgery, respectively. with few signs of improvement (17). Building on WHO’s earlier work carried out jointly with the World Alliance The scale and speed of implementation of these for Patient Safety, this led to consolidation and further Challenges were unprecedented. They secured strong development of the second phase of WHO’s global and rapid commitment from ministers of health, patient safety programme. professional bodies, regulators, health system leaders, civil society organizations and health care practitioners. WHO established major global patient safety initiatives, engaged with a large number of stakeholders and partners, and held large-scale and high-level Other initiatives of the World Alliance for consultations, including: Patient Safety The third WHO Global Patient Safety Challenge: In addition to designing and implementing the two Medication Without Harm, launched as a multi- Global Patient Safety Challenges, the World Alliance year initiative with the goal of reducing the severe, for Patient Safety established the following range of avoidable medication-related harm globally by 50% landmark initiatives in its initial work programme, which over a period of five years; continued during the Alliance’s lifetime: Global Patient Safety Network, a highly interactive Patients for Patient Safety programme, led by network established in collaboration with Member individuals who had suffered harm from health care States, health care leaders, international experts and or by their family members; professional bodies; Taxonomy for Patient Safety initiative, ensuring Global Ministerial Summits on Patient Safety consistency in the norms and terminology used initiated by the Governments of the United Kingdom in patient safety work, as well as a classification of Great Britain and Northern Ireland Ireland and framework – the International Classification for Germany in collaboration with WHO since 2016, as a Patient Safety; series of annual summits; Patient Safety Research initiative to identify World Health Assembly resolution WHA72.6 on priorities for patient safety-related research in high-, “Global action on patient safety”, adopted in May middle- and low-income countries, as well as projects 2019, and outlined a comprehensive and multifaceted and capacity-building; patient safety strategy; 4 | Draft Global Patient Safety Action Plan 2021–2030 Global Patient Safety Collaborative, launched in together with the capacity and financial stability of collaboration with the Government of the United health care delivery systems. Situational factors, such as Kingdom to collaborate with low- and middle-income staffing shortages, staff redeployment to unfamiliar roles, countries to reduce the risk of avoidable patient and “workarounds”, all disrupted existing care processes harm; in most health systems worldwide. In addition, the World Patient Safety Day, established by World indirect effects of the virus on access to unrelated areas Health Assembly resolution WHA72.6, the first of of care emerged as another form of serious harm. Delays which was held on 17 September 2019; the 2020 arose from patients not seeking care due to fear, people event was dedicated to health worker safety and unable to go to health facilities because of lockdowns, launched a landmark charter Health worker safety: a those with complex chronic conditions not receiving priority for patient safety, among other advocacy and their routine ambulatory or preventive care due to health technical products; system overload, or COVID-19 admissions being given priority. In addition, patients experienced new types of Publication of patient safety normative guidance diagnostic errors, some related to the virus and others and tools, including the Technical Series on Safer not as much (18). Primary Care, the Safe Childbirth Checklist and accompanying implementation guide, the Minimal Despite these negative effects and risks, the COVID- Information Model for Patient Safety Incident 19 pandemic has provided some short-term benefits Reporting and Learning Systems (technical report in key areas that could be a catalyst for subsequent and guidance), and technical reports on medication improvement strategies. Shared commitment and safety, among other WHO guidance and tools; responsibility have united health care stakeholders as never before. Many have spontaneously adopted Africa Patient Safety Initiative, a high-level forum key safety attributes such as transparency, active jointly organized with key partners for working with communication, collaboration and rapid adoption of countries in Africa to improve patient safety; patient safety practices. This may only be temporary WHO Flagship Initiative “A Decade of Patient and in selected settings and countries, but it illustrates Safety 2020–2030” launched to guide and support how traditional silos and clinical territories can rapidly strategic action on patient safety at the global, dissolve in the interest of fighting a common enemy. regional and national levels. The flagship initiative’s core work involves formulation of the Global Patient It is sobering to realize that the chronic and widespread Safety Action Plan and supporting its implementation public health crisis of avoidable patient and workforce at all levels through advocacy, normative guidance harm will remain as much of a challenge as before when and tools, strategic partnerships, campaigns, the COVID-19 pandemic is over. The next five years will collaboration, patient and family engagement, be a time for the global patient safety movement to learn knowledge sharing and technical work on building from both the negative and positive effects of COVID-19. and strengthening patient safety systems and It will be a time to build safer health care systems that practices. minimize harm to patients and to health workers. This global action plan is built from a deep understanding of the nature of avoidable harm in health care and the 1.1.4 Coronavirus disease way in which it threatens patient safety in diverse and (COVID-19): a broader concept complex settings across the globe. Thinking through how of avoidable harm COVID-19 adds to this context will help to harvest patient safety lessons from both pandemic failures and pandemic In 2020, the toll of the COVID-19 global pandemic transformations. This is all part of the urgent need to “build brought increased recognition of risks to patients. The back better” and “hardwire” positive changes, to promote ongoing impact on health care delivery systems around the spread of safety strategies and innovations, and to the world will become clearer and fully quantified over make health care systems more resilient to the impact of time. However, important patient safety implications harm than ever before. have emerged, giving heightened impetus to efforts that promote safer care at every level. Growing clinical familiarity with the SARS-CoV-2 virus and its 1.2 Mandate manifestations began to reduce uncertainty, but with the new disease and its novel treatments came the greater The Global Patient Safety Action Plan 2021–2030 draws risk of avoidable harm. The physical and psychological its mandate from World Health Assembly resolution safety of health workers was widely compromised, WHA72.6 on “Global action on patient safety”. The Introduction | 5 resolution requested the Director-General of WHO References: Chapter 1 “to formulate a global patient safety action plan in 1. Mannion R, Braithwaite J. False dawns and new horizons in consultation with Member States and all relevant patient safety research and practice. Int J Health Policy Manag. stakeholders, including in the private sector”. The plan 2017;6:685–9 (https://dx.doi.org/10.15171%2Fijhpm.2017.115, must be submitted to the Seventy-fourth World Health accessed 25 March 2021). Assembly in 2021 through the 148th session of the WHO 2. Institute of Medicine. 2001. Crossing the quality chasm: a new Executive Board. The operating paragraphs of resolution health system for the 21st century. Washington (DC): National WHA72.6 delineate the strategic and operational Academies Press (https://www.nap.edu/read/10027, accessed boundaries of this action plan (19, 20). 28 March 2021). 3. Kohn LT, Corrigan JM, Donaldson MS, editors. Institute of Medicine. To err is human: building a safer health system. 1.3 Development process Washington (DC): National Academies Press; 2000 (https:// www.nap.edu/read/9728/chapter/1, accessed 25 March 2021). This global action plan was co-developed through a 4. Department of Health. An organisation with a memory: participative process with the contribution of leading report of an expert group on learning from adverse events international experts on patient safety. The draft went in the NHS chaired by the Chief Medical Officer. London: The through multiple rounds of stakeholder consultations Stationery Office; 2000 (https://qi.elft.nhs.uk/wp-content/ including Member States, international organizations, uploads/2014/08/r_02-an-organisation-with-a-memory-l- academic institutions, patient groups, intergovernmental donaldson.pdf, accessed 25 March 2021). organizations, and WHO global, regional and country 5. Delivering quality health services: a global imperative for offices. The initial outline and development pathway universal health coverage. Geneva: World Health Organization, of the action plan was developed by the Patient Safety Organisation for Economic Co-operation and Development, World Bank; 2018 (https://www.worldbank.org/en/topic/ Flagship secretariat at WHO headquarters in Geneva, with universalhealthcoverage/publication/delivering-quality-health- the guidance and support of WHO Patient Safety Envoy, services-a-global-imperative-for-universal-health-coverage, and in consultation with relevant technical programmes, accessed 25 March 2021). units and departments within the WHO system. A WHO 6. Slawomirski L, Auraaen A, Klazinga N. The economics of patient global consultation was convened in February 2020 at safety: strengthening a value-based approach to reducing WHO headquarters in Geneva to synthesize the first patient harm at national level. OECD Health Working Papers draft of the action plan. Leading patient safety experts No. 96. Paris: Organisation for Economic Co-operation and and practitioners from 44 countries provided invaluable Development; 2017 (https://doi.org/10.1787/5a9858cd-en, concrete recommendations on what should be the future accessed 25 March 2021). course of global action on patient safety. Additional 7. National Academies of Sciences, Engineering, and Medicine; inputs were received from experts and stakeholders Health and Medicine Division; Board on Health Care Services; through the WHO Global Patient Safety Network. Board on Global Health; Committee on Improving the Quality of Health Care Globally. Crossing the global quality chasm: A drafting and review task force was constituted with improving health care worldwide. Washington (DC): National the mandate to take forward the recommendations Academies Press; 2018. from these consultations and prepare the draft action 8. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder- plan. The first draft was further discussed with Member DeWan S et al. High-quality health systems in the Sustainable States through regional committees and consultations. Development Goals era: time for a revolution. Lancet Glob Health. 2018;6(11):e1196-e1252. doi:10.1016/s2214- Additional technical briefings were organized with 109x(18)30386-3t. permanent country missions in Geneva. The draft action plan was made available online for public 9. Woods D, Thomas EJ, Holl JL, Weiss KB, Brennan TA. Ambulatory care adverse events and preventable adverse events leading consultation on the WHO website for a period of one to a hospital admission. Qual Saf Health Care. 2007;16:127–31. month. Feedback, comments and technical input doi:10.1136/qshc.2006.021147. from Member States and from the outcome of the 10. NHS Litigation Authority. Annual report and accounts 2017/18. public consultation were reviewed and appropriately London: Her Majesty’s Stationery Office; 2018 (https://resolution. addressed by the drafting and review task force. An nhs.uk/wp-content/uploads/2018/08/NHS-Resolution-Annual- advanced draft of the action plan was submitted to the Report-2017-2018.pdf, accessed 25 March 2021). 148th session of the Executive Board in January 2021 for 11. Aitken M, Gorokhovich L. Advancing the responsible use of review, discussion and approval. At its 148th session the medicines: applying levers for change. Parsippany (NJ), United Executive Board adapted a decision to recommend the States of America: IMS Institute for Healthcare Informatics; global action plan for approval of seventy fourth World 2012 (https://papers.ssrn.com/sol3/papers.cfm?abstract_ Health Assembly. id=2222541, accessed 25 March 2021). 6 | Draft Global Patient Safety Action Plan 2021–2030 12. Slawomirski L, Auraaen A, Klazinga N. The economics of 17. WHO global consultation: setting priorities for global patient safety in primary and ambulatory care: flying blind. patient safety. Executive summary. Geneva: World Health OECD Health Working Papers No. 106. Paris: Organisation for Organization; 2016 (https://www.who.int/patientsafety/ Economic Co-operation and Development; 2018 (https://doi. executive-summary_florence.pdf, accessed org/10.1787/baf425ad-en, accessed 25 March 2021). 25 March 2021). 13. Slawomirski L, Klazinga N. Economics of patient safety: from 18. Ensuring a safe environment for patients and staff in COVID-19 analysis to action. Paris: Organisation for Economic Co- health-care facilities. Geneva: World Health Organization; 2020 operation and Development; 2020 (http://www.oecd.org/ (https://www.who.int/publications/i/item/WHO-2019-nCoV- health/health-systems/Economics-of-Patient-Safety-October- HCF_assessment-Safe_environment-2020.1, accessed 25 March 2020.pdf, accessed 25 March 2021). 2021). 14. World Alliance for Patient Safety: forward programme. Geneva: 19. Resolution WHA72.6. Global action on patient safety. In: World Health Organization; 2004 (https://www.who.int/ Seventy-second World Health Assembly, Geneva, 20–24 May patientsafety/en/brochure_final.pdf, accessed 25 March 2021). 2019. Geneva: World Health Organization; 2019 (https://apps. who.int/gb/ebwha/pdf_files/WHA72/A72_R6-en.pdf, accessed 15. World Alliance for Patient Safety. Global Patient Safety 25 March 2021). Challenge 2005–2006. Clean Care is Safer Care. Geneva: World Health Organization; 2005 (https://www.who.int/patientsafety/ 20. Patient safety: global action on patient safety: report by the events/05/GPSC_Launch_ENGLISH_FINAL.pdf?ua=1, accessed Director-General. In: Seventy-second World Health Assembly, 25 March 2021). Geneva, 20–24 May 2019. Geneva: World Health Organization; 2019 (https://apps.who.int/gb/ebwha/pdf_files/WHA72/ 16. World Alliance for Patient Safety. The second WHO Global A72_26-en.pdf, accessed 25 March 2021). Patient Safety Challenge: Safe Surgery Saves Lives. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/ bitstream/handle/10665/70080/WHO_IER_PSP_2008.07_ eng.pdf?sequence=1&isAllowed=y, accessed 25 March 2021). Introduction | 7 2. Vision, Mission and Goal Vision A world in which no one is harmed in health care and every patient receives safe and respectful care, every time, everywhere Mission Drive forward policies, strategies and actions based on science, patient experience, system design and partnerships to eliminate all sources of avoidable risk and harm to patients and health workers Goal Achieve the maximum possible reduction in avoidable harm due to unsafe health care globally 8 | Draft Global Patient Safety Action Plan 2021–2030 3. Guiding principles C reating a system for progressing towards universal health coverage in which patients are safer than they are today, especially at the point they receive care 3.2 Achieve results through collaborative working anywhere in the world, is a major challenge. It is this With A Decade of Patient Safety 2020–2030 initiative challenge that is addressed in the Global Patient Safety as a global mandate, WHO will provide policy guidance Action Plan 2021–2030. The following seven guiding and implementation tools to countries to make health principles establish an underpinning set of values to care safer at the point of delivery. There will inevitably guide the development and implementation of the be disruptive innovations and newer models of safer framework for action proposed in the global action care evolving at local level. They should feed into global plan. The framework includes seven strategic objectives learning systems to redesign the policy architecture and and 35 strategies that are the foundation of the global promote global discourse on patient safety. Rather than action plan. a unidirectional flow of interventions, there is a need for a collaborative ecosystem whereby everybody (from global policy-makers to front-line service providers) 3.1 Engage patients and contributes, shares and learns. All patient safety families as partners in interventions will need to be carefully designed and safe care tailored to meet countries’ and communities’ priorities, as well as their specific implementation needs. WHO will Safe health care should be seen as a basic human drive harm reduction impact in every country through right. As health care is predominantly a service, it is policy dialogue, strategic support, technical assistance always co-produced with the users. Achieving safe for safer service delivery. Global action can help, but care requires that patients be informed, involved and the strength of the plan will lie in the passion and treated as full partners in their own care. In many parts commitment for patient safety shown at the national, of the world, this happens much less than it should. subnational and local levels. Patients, families and caregivers have a keen interest in their own health and that of their communities. 3.3 Analyse and share data Patient safety depends on their full involvement as the users of the health care system and the people to generate learning who are most familiar with the entire patient journey. Reporting systems that gather data about adverse events Patients and families should be involved at every and incidents from the point of care are widespread level of health care, ranging from policy-making and throughout the world. In 2020, WHO produced the planning, to performance oversight, to fully informed document Patient safety incident reporting and learning consent and shared decision-making at the point of systems: technical report and guidance. There are other care. Patients, families and communities have essential sources of such data, including malpractice claims, contributions to make in patient safety. patient-reported experience and outcome measures, Guiding principles | 9 clinical care audits, medical record reviews, surveys, of finding patient safety solutions in resource-limited significant event audits, and safety surveillance data for settings can be of value to those running programmes in blood products, medicines, vaccines and medical devices. well-resourced health care systems, as well as the usually Gathering data from these various sources provides a rich favoured “North–South” route for advocating best practice. opportunity to gain greater understanding of why safety incidents occur and to devise solutions to prevent them. However, too often, great volumes of data are collected 3.6 Use both scientific and most of the available time and resources are spent expertise and patient storing them. Less time is spent on analysing and sharing data in a way that is usable for learning and can reliably experience to improve and consistently contribute to improving patient safety. safety There are also issues of data quality and reliability, which Today, developing safe services for patients does not could best be addressed through building a culture of only involve the skills of planning, design and strategic trust in reporting. Whilst it is always of interest to use such investment, it also involves advocacy, awareness data to provide information on patterns and trends in the raising, political commitment, persuasion and localism. types of harm that occur, the emphasis must be firmly on Traditionally, the scientific and technical expertise comes their capability to make future care safer. from the policy-makers, health system leaders, health care professionals, academics and managers, whilst the 3.4 Translate evidence passion comes from the citizens, civil society organizations and patient advocates. Formulating and delivering a plan into actionable and requires scientific and technical expertise, but it also must measurable improvement have the buy-in and positive emotional drive of those who remember that too many past patients and families An area of weakness in many parts of health care, including have suffered loss and serious harm as a result of flawed patient safety, is the slow translation of evidence of health care. If these two elements – science and personal effectiveness into routine practice: what is sometimes experience – are always brought together in improvement, called the “knowing–doing” gap. There is also a wealth of it will be a winning combination. provider and patient experience and tactical knowledge available for designing and testing solutions to improve patient safety. During the process of framing actions to 3.7 Instil a safety culture in improve patient safety, it is important to fully understand the process of change and utilize the established body of the design and delivery knowledge on improvement science to achieve the desired of health care outcome. This also means working closely with leaders, Developing a culture of safety is cardinal to any sustainable managers, professional staff and patient representatives efforts towards patient safety improvement. Policy in health facilities and clinical services. It is also important and legislative interventions can provide a conducive to nurture centres of excellence, learn from them, and environment for a flourishing safety culture. Ultimately, scale up proven best practices. though, a culture of safety has to percolate into the attitudes, beliefs, values, skills and practices of health workers, managers and leaders of health care organizations. The 3.5 Base policies and action safety culture must intertwine with the overall organizational on the nature of the care philosophy and culture. Countries and organizations can setting identify their own optimal ways of achieving a culture of safety, though certain elements remain indispensable. Most of the attention and research endeavour in patient Leadership commitment, transparency, open and respectful safety has focused on the experience of high-resourced communication, learning from errors and best practices, health care systems and large hospital groups. Yet, a great and a judicious balance between a no blame policy and deal of good work has been taking place in low-resource accountability are indispensable components of safety settings. First, it has become clear that patient safety culture. A strong safety culture is not only core to reducing policies and solutions must be adapted to the local context. patient harm, it is also critical for providing a safe working They do not simply translate from one setting to another, environment for health workers. This includes creating a especially where the culture, traditions, health care system psychologically safe work environment, whereby health design and level of infrastructure can be very different. workers can speak up regarding patient safety and other Second, learning is not just a one-way flow. The experience concerns without fear of negative consequences. 10 | Draft Global Patient Safety Action Plan 2021–2030 4. Partners in action C omprehensive action on patient safety across all countries worldwide is a complex endeavour and requires the collective efforts of numerous stakeholders, ranging from policy-makers to health workers. To achieve the goal and strategic objectives of the Global Patient Safety Action Plan 2021– 2030, it is important that partnerships develop at both the strategic and the operational levels. Collaboration in this way will add particular value to patient safety endeavours and strengthen the efforts of individual organizations. By working together to achieve the vision of the action plan and improve the safety of care for all, partners can also accelerate progress to achieve their own respective goals. As shown below, four broad categories of partners have been identified to support implementation of the global action plan. The action plan also envisages patients, families and communities as key partners at all levels of action. 4.1 Governments National and subnational governments Parliament and subnational legislative bodies Ministries of health National and subnational specialized agencies and adjunct bodies, for example, national patient safety and quality institutes, centres or agencies, including planning agencies, scheme implementation bodies, public health institutions, and occupational health agencies Other ministries directly or indirectly involved in health, including ministries of education, finance, labour and 4.2 Health care facilities social affairs, consumer affairs, justice and territorial administration and services Tertiary and secondary care facilities and health care National and subnational regulatory bodies, including organizations standard setting, licensing and accreditation agencies, Primary care facilities and service providers and health care safety investigative bodies Long-term care facilities and service providers Palliative care service providers Mental health facilities and service providers Pre-hospital care service providers Specialized clinics and diagnostic service providers Substance use disorder facilities and dementia care facilities Outreach health care service providers Community-based and home-based health care service providers Subnational and district health service management teams Partners in action | 11 4.3 Stakeholders Intergovernmental organizations, for example, European Commission, OECD International and national nongovernmental organizations Iinternational development organizations International and independent standard setting bodies and accreditation agencies International and national professional bodies and scientific associations and societies Universities, academic institutions, educational centres and other international and national training and capacity-building institutions Research institutions International and national consortiums and associations of health service providers Trade unions and other labour organizations representing health workers International and national civil society organizations, including patient organizations Community groups and organizations Media, including print, electronic and social media United Nations and other multilateral organizations Development partners, donors and funding agencies Pharmaceutical and medical devices industry Health care information technology industry Private sector entities, including commercial businesses (industry) and health service provider organizations Health insurance and maintenance organizations 4.4 The WHO Secretariat WHO at all levels – country offices, regional offices and headquarters WHO geographically dispersed offices 12 | Draft Global Patient Safety Action Plan 2021–2030 5. Framework for action The framework includes seven strategic objectives, which can Make zero avoidable harm to 1 be achieved through 35 specific patients a state of mind and a rule of engagement in the strategies: planning and delivery of health care everywhere Build high-reliability health systems and health organizations that protect patients daily 2 Assure the safety of every clinical from harm 3 process 4 Engage and empower Inspire, educate, patients and families skill and protect to help and support health workers to the journey to safer 5 contribute to the health care design and delivery of safe care systems Ensure a constant flow 6 of information and Develop and sustain knowledge to drive multisectoral and the mitigation of risk, multinational a reduction in levels of synergy, partnership avoidable harm, and improvements in the safety of care 7 and solidarity to improve patient safety and quality of care Framework for action | 13 Framework for Action - The 7x5 Matrix 1.1 1.4 1.5 Policies to Patient safety 1.2 1.3 1 Safety World Patient eliminate policy, strategy Resource Protective standards, Safety Day and avoidable harm and mobilization and legislative regulation and Global Patient in health care implementation allocation measures accreditation Safety Challenges framework 2.3 2.4 2.2 2.5 2.1 Leadership Human 2 Good Patient safety High-reliability Transparency, capacity for factors/ governance in emergencies systems openness and clinical ergonomics for for the health and settings of No blame culture and managerial health systems care system extreme adversity functions resilience 3.3 3.4 3.2 3.5 3.1 Infection Safety of 3 Global Patient Patient safety Safety of clinical Safety of prevention and medical devices, Safety Challenge: in primary care processes risk-prone clinical control & medicines, Medication and transitions procedures antimicrobial blood and Without Harm of care resistance vaccines 4.1 4.2 4.4 4.5 4.3 4 Co-development Learning from Patient safety Information and Patient and family Patient advocates of policies and patient experience incident education to engagement and patient safety programmes with for safety disclosure to patients champions patients improvement victims and families 5.2 5.1 5.3 5.4 Health worker Centres of 5.5 5 Patient safety Patient safety Linking patient education, skills excellence for Safe working in professional competencies as safety with and safety patient safety environment for education and regulatory appraisal system education health workers training requirements of health workers and training 6.1 Information, 6.2 6.3 6.4 6.5 6 Patient safety research and risk incident reporting Patient safety Patient safety Patient safety Digital management information surveillance research technology and learning systems systems programmes for patient safety systems 7.2 7.4 7.5 Synergy, 7.3 7 7.1 Common Cross geographical Alignment with partnership Patient safety Stakeholders understanding and multisectoral technical and solidarity networks and engagement and shared initiatives for programmes collaboration commitment patient safety and initiatives 14 | Draft Global Patient Safety Action Plan 2021–2030 Strategic objectives and so that it is entirely permissible within their scope to formulate programmes of action that fit with local needs implementation strategies and priorities and that are shaped by the specific context. Few large organizations in any sector across the world They do this precisely because they are intended to operate effectively without a clear, simple set of objectives empower and not to constrain. So, for example, Objective 2 has meaning whether “high reliability” is being developed that govern strategic and operational activities and are in a teaching hospital in Western Europe or in a rural understood and owned by all staff. Establishing these at health centre in a poor country in West Africa. Each will be high-level for a system helps to focus all existing policies aiming to do the very best they possibly can within their and activities of the health care system towards a common operating context and resource availability. purpose. If few in number, and appropriately formulated, they can enable progress to be reviewed at strategic level In turn, Objective 3, which deals with the important and also at the level of the clinical team. The objectives area of designing and operating safe care processes and should not create an extra burden, nor replace existing pathways, is equally applicable to a high technology measures of performance within countries, nor in their maternity service in a large Canadian city as it is to a systems and facilities. Instead, they should serve to unify service in a remote part of Sierra Leone trying to reduce the work of the leadership, the endeavours of managers maternal deaths from post-partum haemorrhage. and the care of doctors, nurses and other health workers. They should provide a test of everything from everyday The strategic objectives are also intended to be easily clinical work to big strategic decisions about the design understood and envisioned, readily communicated, and of health care systems. They should also provide a simple have an uplifting and inspiring tone as well as being few public accountability framework. enough in number not to prove daunting and to cause implementation overload. The framework of action is further That is the purpose of the seven strategic objectives elucidated through 35 strategies, five under each of the this framework provides for the global action plan. They strategic objectives, to create a seven by five matrix. Each are broad enough to make sense of the myriad of tasks strategy has been further elaborated into suggested actions required to reduce the risks and to improve the safety of for four sets of partners: governments, health care facilities patient care in every part of the world. They are articulated and services, stakeholders and the WHO Secretariat. Framework for action | 15 Strategic Objective 1 Policies to eliminate avoidable harm in health care Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere This first objective, dealing with the idea of zero harm, has patient safety. This can be seen across the world, within been very carefully judged. Arguments range in global countries, between regions and localities, throughout health circles about the wisdom of setting a central or fields of care. Errors provoked by flawed systems are overarching goal. On the one hand, some people say common and continue to harm people. These problems that without a compelling vision, a programme will have are not unique to any one health system, but over the no chance of adoption amongst the many global health years they have proved mostly intractable. programmes that set their direction on a highly desirable and beneficial outcome for humanity. Others claim Yet, the reduction of the currently unacceptable levels that setting an unreachable goal is demoralizing and of avoidable harm is entirely within reach. Certainly, demotivating and will not attract people to its cause. The zero harm is unlikely to be achieved in any foreseeable Global Patient Safety Action Plan 2021–2030 sets a vision timescale. But no one would argue that any harm caused and philosophy of zero harm, rather than a concrete to a recipient of health care should be tolerated. Getting target. the numbers down to zero will not be possible for now. However, a mindset of zero harm and a frame of reference The need for a bold holistic objective to address the very for planning and delivering health care would be a seismic existence of harm itself stems from the need to accept shift from the current status quo that lives with high full accountability for solving definitively the problems levels of avoidable harm. Basing every thought in every that underlie safety, risk and harm in health care. The plan, every step in the design of every programme, every discourse on patient safety and its multifaceted nature decision in every clinical encounter, every opportunity to over the last 20 years has not been enough to infuse learn when something goes wrong, on this philosophy leaders, clinicians and managers with the focus and would create a new paradigm in health care. It will be truly commitment to drive major improvements in patient transformative and, far from being purely idealistic and safety. Nor have the shocking numbers that paint intangible, it has the potential to make huge reductions the stark picture. To this day, health care systems and in death, disability, and physical and psychological injury facilities deliver very variable levels of performance in from unsafe care. 16 | Draft Global Patient Safety Action Plan 2021–2030 Strategic objective 1: Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere Strategy 1.1: Actions for governments Recognize patient safety as a health priority in health sector policies and programmes, Develop a making it an essential component for strengthening health care systems in order to achieve universal health coverage. comprehensive patient safety Establish a national patient safety programme supported by a patient safety policy, strategy, policy, strategy, institutional framework and action plan within the health care context in the country, institutional including overall health priorities and goals; current levels and sources of avoidable risks framework and and harm; resources available; and both public and private sector service providers. action plan for the Work in collaboration with other countries, civil society organizations, patient country’s health organizations, professional bodies, academic and research institutions, industry and system and all its other relevant stakeholders to promote, prioritize and embed patient safety in all health components as a key policies and strategies. priority in working Map the existing national health policy and strategy landscape, including universal health towards universal coverage, primary health care, quality of care and health workforce, to create maximum health coverage opportunities for synergies with the patient safety policy framework. Integrate implementation with safety-critical technical programmes such as surgical safety, medication safety, blood safety, radiation safety, immunization safety, medical device safety, infection prevention and control and antimicrobial resistance, while establishing a national patient safety programme. Adapt WHO patient safety technical guidance, implementation strategies and tools to the national context and build capacity in patient safety. Create a national patient safety charter that includes institutional standards and patients’ and health workers' rights and responsibilities. Actions for health care facilities and services State a clear public commitment that the organization is working to orient culture and practices towards zero avoidable harm. Align and implement processes and practices at the facility level with patient safety guidelines, protocols and standard operating procedures. Review progress on patient safety performance at the organization’s main management committee meetings and all other key governing body meetings. Actions for stakeholders Advocate patient safety as a strategic priority for Member States and health care organizations. Engage with professional organizations and patient organizations to develop and implement the patient safety goals, objectives and values. Participate in, support and facilitate patient safety programmes at local, national and global levels. Actions for the WHO Secretariat Provide high-level advocacy and guidance at global, regional and national levels to create a vision for eliminating avoidable harm in health care. Identify patient safety as a key strategic priority in WHO’s work across the universal health coverage agenda, and in global strategies and interventions for achieving universal health coverage. Framework for action | 17 Develop and disseminate guidance and tools for the formulation of national patient safety policy, strategy, framework and action plans. Collate and disseminate best practices in developing and implementing patient safety policies, strategies and plans. Strategy 1.2: Actions for governments Allocate adequate human resources and sustainable finances for a national patient safety Mobilize and plan within the financial structure of the health system through mechanisms such as a allocate adequate specific budget, health insurance or other mechanisms. resources for Produce an annual budget and human resource plan for a national patient safety action plan. patient safety Take steps to limit overcrowding in hospitals through optimal resource planning, primary implementation care gatekeeping, scientific layout and process design, and other evidence-based throughout every interventions. level of the health Ensure sufficient funding to deliver needs-based safe staffing and establish effective care system human resource planning to ensure an adequate supply of health workers to meet patient and population needs. Explore whether the system of funding of health care in the country can be adjusted to reward health organizations that achieve performance on patient safety. Actions for health care facilities and services Incorporate activities for patient safety implementation in the organization’s overall operational plan, including annual budget and human resource plan. Allocate adequate financial resources for patient safety implementation at the organizational level. Provide an adequate level of staffing with an appropriate skills mix; develop information systems based on reliable real-time data, agreed metrics, benchmarking and best practices to inform evidence-based planning. Ensure optimal staffing, infrastructure, layout and process flow to limit overcrowding in health care facilities. Actions for stakeholders Advocate provision of adequate human and financial resources to tackle the most serious patient safety problems. Engage the private sector to help it define its role in improving patient safety. Publicize patient safety solutions to garner public support. Advocate measures to address overcrowding in health care facilities at the local, national and global levels. Actions for the WHO Secretariat Provide advocacy to Member States and partners for sustainable financial mechanisms and allocation of adequate resources for patient safety implementation, and support resource mobilization. Create organizational structures with dedicated teams and provide adequate human and financial resources across WHO for patient safety activities. Mobilize, allocate and provide guidance on assessing and obtaining adequate resources for patient safety campaigns, initiatives, programmes and consultations, and for country cooperation and technical support. Provide guidance and recommendation for policies and tools to limit overcrowding in health care facilities. 18 | Draft Global Patient Safety Action Plan 2021–2030 Strategy 1.3: Actions for governments Use selective Review and develop legislation governing the country’s health system to facilitate the legislation to formulation and implementation of patient safety policies, practices and behavioural norms. facilitate the Develop legislation to protect health workers from retaliation or punitive action in the case delivery of safe of reporting an adverse event; introduce mandatory licensing schemes for health care patient care and professional that incorporate patient safety aspects; recognize patient safety as a human the protection of right incorporating access to safe medicines, medical devices, blood products, and essential patients and health health services. workers from avoidable harm Actions for health care facilities and services Leverage opportunities through existing national legislation to strengthen measures to protect patients and health workers from avoidable harm and to systematically improve patient safety. Map regulatory and statutory requirements applicable to health care facilities and ensure full compliance, including obtaining and timely renewal of all licences. Actions for stakeholders Coordinate professional organizations, civil society organizations, patient and community groups, and other bodies with an interest in patient safety to identify scope for new legislation, and then advocate to lawmakers and national government to enact such measures. Partner with patient-led organizations to raise public awareness of the impact that safe staffing has on patients, families and communities. Actions for the WHO Secretariat Provide advocacy and technical support to Member States in developing and amending legislation for improving patient safety and health worker safety. Collate and disseminate best practices in legislation for the protection of patients and health workers from avoidable harm. Strategy 1.4: Actions for governments Align health Define and incorporate minimum patient safety standards in regulatory requirements for care regulatory, health care facilities. inspectorial and Include or augment patient safety as a key component of voluntary accreditation accreditation standards and award criteria. activities with the Include patient safety requirements in health system performance assessment. goal of improving performance on Mandate patient safety requirements in licensing and relicensing schemes for health patient safety care professionals. Actions for health care facilities and services Implement the licensing, regulatory and accreditation requirements for patient safety in all service areas. Communicate to all staff on a regular basis about patient safety licensing, regulatory and accreditation systems that the organization is signed up to. Incorporate a culture of continuous improvement of patient safety utilizing principles of quality improvement. Feed information back to national government on the ways in which licensing, regulatory and accreditation systems could be improved to better facilitate the achievement of higher standards of patient safety. Framework for action | 19 Actions for stakeholders Adequately address patient safety requirements in international accreditation standards and programmes. Convene researchers and research bodies to create an evidence base (including commissioning new research where necessary) on the effectiveness of licensing, regulatory and accreditation systems in improving patient safety. Bring together experts, health system leaders and civil society organizations to establish the ways to interpret and use patient safety performance information produced from the processes of licensing, regulation and accreditation of health care facilities and professionals. Actions for the WHO Secretariat Provide technical support and expert guidance for Member States to build patient safety strengthening measures into their national health care licensing, regulatory and accreditation systems. Develop normative guidance on minimum standards for patient safety. Strategy 1.5: Actions for governments Create max

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