*EPF308 10/27/2004
World Health Officials Launch Patient Safety Initiative
(Aim is to recognize, and reduce, potential for medical error) (850)

By Charlene Porter
Washington File Staff Writer

Washington -- Global health leaders are joining an international alliance to reduce illness, injury, mistreatment and death suffered by patients in medical care.

In announcing formation of the World Alliance for Patient Safety October 27, experts produced studies indicating that as many as 16 percent of patients in developed world hospitals may receive care or treatment that does them harm. It is estimated that the rate of injury is even higher in resource-poor, medical-care settings in the developing world.

It was not statistics, but a woman -- a wife, a mother, a victim -- who presented the most compelling evidence of the need for this initiative. Susan Sheridan has lived a double tragedy of blunder in the health-care setting and now represents an organization called Consumers Advancing Patient Safety. She joined leaders of the World Health Organization (WHO) and the U.S. Department of Health and Human Services (HHS) as a partner in the campaign to focus greater attention on what can go wrong in medical settings.

Sheridan has a son who lives now with multiple disabilities due to her physicians' underestimation of the severity of jaundice he experienced in the first few days of life.

"Cal is 9 years old. He walks with a walker, he needs a wheelchair for long distances. He is speech-impaired; he is hearing-impaired. He drools. His teeth didn't form right, his eyes crossed at age 4, all because of the failure to administer a test that cost one dollar," Sheridan said.

Sheridan's experience with medical error has a second tragic chapter, which she recounted in a voice shaking with emotion. Several years after her son's birth, her husband died from a rapidly spreading cancer, after the family had initially been told that his condition was benign.

Almost as devastating as the loss of her husband and the disability of her child, Sheridan said, is the lack of honesty from her family's physicians about the errors that occurred under their care.

"To err is human, but to cover up is unforgivable," Sheridan told her audience of health care officials. "I know of no other industry where honesty is optional."

Creating greater honesty about medical error and better approaches for recognizing its likelihood are key elements in the plan to strengthen patient safety in medical institutions worldwide, according to Sir Liam Donaldson, the chief medical officer of the Department of Health in the United Kingdom and the chair of the World Alliance for Patient Safety.

The medical establishment has too long believed in "the myth of infallibility," Donaldson said, failing to recognize that "human error is inevitable." The patient safety alliance will attempt to recognize the potential for error, reduce its likelihood and, therefore, its impact.

Donaldson said that creating greater patient safety also depends on changing current responses of blame and retribution in the aftermath of error and honest mistake. He said it is unwise to create an environment in which medical staffs fear being forthright about mistakes because the opportunities to learn from mistakes will be lost.

Donaldson said the upcoming work of the patient safety alliance will focus on six areas, including reducing health-care-associated infection, adoption of consistent norms and principles in patient safety, and further research into the occurrence of harmful events.

The United States health establishment began focusing on patient safety in 1999 with publication of a report from the Institute of Medicine that demonstrated a frequency of error in health care that shocked the public and medical practitioners. Since then, the Agency for Healthcare Research and Quality (AHRQ) at HHS has been working to improve what AHRQ Director Carolyn M. Clancy calls an "epidemic of medical errors."

Her agency has compiled a guide for patients entitled "20 Tips to Prevent Medical Errors," which is being distributed in the United States and has also been adopted by Japan and Australia. ARHQ is also promoting constant vigilance in maintaining cleanliness in the health-care setting, Clancy said, and is working to develop a common vocabulary that medical workers can use when discussing issues of patient safety.

She also said that U.S. health officials recognize that the problems of patient safety they are trying to solve at home are far different from those encountered by health officials in developing-world nations. "We will help those countries that don't normally have deep financial support or research infrastructure, but do have a commitment to improve their health care system with innovate and creative ideas," she said.

The patient safety movement began gaining momentum in 2002 when the World Health Assembly, the governing authority of the WHO, adopted a resolution urging member states to strengthen safety and monitoring systems. So far, interest in pursuing these initiatives has been expressed by 140 nations, which Donaldson calls "an unprecedented" number.

A broad view of international patient safety initiatives is available at a portal established by the World Health Organization at http://www.who.int/patientsafety/en/

(The Washington File is a product of the Bureau of International Information Programs, U.S. Department of State. Web site: http://usinfo.state.gov)

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