Project Background and Information

Collaboration between the Health Information and Quality Authority, Ireland and the World Health Organization’s World Alliance for Patient Safety

1. Introduction

Healthcare is undergoing unprecedented changes and healthcare providers are facing many challenges in a rapidly changing environment both in Ireland and internationally. Despite the global commitment to improve the health outputs of patients and provide quality care, there is an increasing awareness that patients receiving care, including care in acute care hospitals, incur injuries and adverse outcomes as a consequence of medical and clinical management.

Research has indicated that significant levels of error occur with health care that often result in injury to patients, in large part due to the complex nature of healthcare delivery. Large scale medical record reviews have been undertaken in Canada, the United States (US) , the United Kingdom (UK) , Australia , Denmark, and New Zealand . These studies have reported rates per admission of adverse events or patient safety incidents as between 7.5% to 12.9% and rates of permanent harm or death from adverse incidents in the range of 0.4% and 2.0%. As yet there has been little research done on the nature and scale of errors in developing and emergent countries. World Health Organization data suggests that developing countries account for 77% of all reported cases of counterfeit or substandard drugs . It is also reported that at least half of all medical equipment in these countries is unusable or only partly usable, resulting in increased risk of harm to patients and health workers.

The Institute of Medicine of the National Academy of Sciences (IOM) in the United States highlighted these issues to the US government in a report To Err is Human. It claimed that 4% of patients incur adverse outcome of treatment and that between 44000 and 98000 Americans a year dies from preventable errors in hospitals. According to estimates from the IOM report, healthcare errors are the fifth leading cause of death in the US and result in annual costs of up to USD29 billion. This report put patient safety to the fore in the US as it called on healthcare to make reduction of errors a priority.

The emerging recognition of the prevalence and consequence of clinical error has led to the emergence of an international drive to create a "culture of safety". In May 2002, the fifty-fifth World Health Assembly (WHA) adopted WHA Resolution 55.18, which urged countries to pay the closest possible attention to the problem of patient safety, and to establish and strengthen science-based systems necessary for improving patient safety and the quality of health care.

In May 2004, the Fifty-seventh WHA supported the creation of an international alliance to facilitate the development of patient safety policy and practice in all Member States and act as a major force for improvement internationally.

The creation of the World Alliance for Patient Safety has been a significant step in the struggle to improve the safety of health care in all Member countries. At present no single player has the expertise, funding, research or delivery capabilities to tackle the full range of patient safety issues on a worldwide scale. Improving patient safety requires carefully designed systems of care, which reduce risks to patients. The World Alliance provides a mechanism to decrease duplication of investment and activities and benefit by economies of scale; solutions identified and evaluated by one or two members could be adapted for global or multicountry implementation.

In Ireland the Health Information and Quality Authority has been established as an independent statutory authority mandated to drive quality and safety in health and social care services in Ireland. The object of the Authority is to promote safety and quality in the provision of health and personal social services for the benefit of the health and welfare of the public.

The Authority is fully committed and focused in its role to drive improvements in the safety of patients and other users of the service and therefore welcomes the development of a strong partnership with the World Health Organization in order to learn from and inform national and international patient safety developments.

Additional Information is available here

For further information please contact:

Hilary Coates
Head of Safety and Learning
Health Information and Quality Authority.
George's Court,
George's Lane,
Dublin 7.

Phone: + 353 1 8147431
Email: patientsafety@hiqa.ie