World Patient Safety Day 2021

The 3rd World Patient Safety Day (established as a recurring event by the World Health Assembly under Resolution WHA72.6 in 2019), took place last Friday, 17 September. This annual observation has several aims, including to • enhance global understanding of patient safety, • increase public engagement in health care safety, and • promote global action to prevent and reduce avoidable harm in health care. Each year, a new priority patient safety area is chosen in order to highlight specifically avoidable health care harms and deficiencies in universal health coverage. This year’s World Patient Safety Day (WPSD) is dedicated to the need to prioritize and address safety in maternal and newborn care in recognition of the significant global burden of harm that women and children suffer due to unsafe care. Since women’s experiences during childbirth are also substantially affected by issues of gender inequity and violence, the WHO has chosen to use WPSD to link the critical ideas of respectful care and women’s safety. WPSD comes at a time when peripartum services have been especially affected by the disruption of health services due to the COVID-19 pandemic, which undoubtedly has imposed a further emotional and psychological burdens on women. There is a significant gap between high and lower income countries in respect of maternal mortality, with 94% of all global maternal deaths occurring in the latter. This geographical difference is equally reflected in neonatal outcomes, although children perhaps fare even less well than women in childbirth. Poverty, poor nutrition, insufficient access to clean water and sanitation, and inaccessibility of quality health services (including vaccination) are all factors that impact upon the globally high rates of preventable death and poor health in newborns and children under the age of five. Ireland has made great strides in neonatal care over the past 60 years. Our infant mortality rate was 30.4 per 1,000 live births in 1960; by 2019 it had fallen to 2.8. Sadly, in some low income countries, the rate of infant death remains devastatingly high at 2-3 times that of Ireland’s 1960 figure. In most instances, children dying within the first 28 days of birth suffer from problems caused by unsafe care at birth, or have conditions and diseases could be readily remediable by access to high quality medical and surgical care. Although maternal and newborn outcomes are substantially better in high-income countries, patient safety concerns remain a persistent issue in maternity services, as evidenced by the many inquiries and reviews into maternal care in Ireland and the UK in the 21st century. The safety issues highlighted by each of the reports are depressingly similar, although they are in no way unique to maternity services: • Failure to listen, • Failure to act on concerns raised by patients and/or family members, • Failure to act on concerns raised by staff, • Problems with multidisciplinary team working, • Persistence of a blame culture discouraging staff raising issues around about unsafe care, • Insufficient staffing levels either numerically or in expertise, • Significant deficiencies in support for patients after critical events. All of these factors make it hard to create the conditions needed to ensure the ‘avoidance of unintended or unexpected harm to people during the provision of healthcare’ insofar as is possible. Many of them also interfere with the need for ‘continuous improvement based on learning from errors and adverse events’. Avoidable harm in healthcare remains a persistent and wide-scale problem that imposes a significant physical and emotional burden on those affected and their families. It perpetuates the loss of trust in the healthcare system within society and, as importantly, the issues outlined above exacerbate the frustration and demoralisation felt by healthcare professionals who work in environments where they are impeded in their efforts to provide safe care. The middle point above (problems with multidisciplinary team working) brings to mind Barbara Cusack’s presentation at the KP Moore Medal competition last year. In examining the quality of interdisciplinary communication in preparation for emergency caesarean sections, anaesthesiologists rated communication as low in quality 80% of the time, compared to 28% of midwives, and 8% of obstetricians. Similarly, 68% of anaesthesiologists felt that preoperative identification of high-risk events was below average, compared to 12% of midwives and 9% of obstetricians. There is clearly much work still to be done on interdisciplinary training, and improving the quality of our communication with other specialties. In this issue of the Newsletter, Niamh Hayes highlights the advances that have taken place in safe maternal care, and the deficiencies that still, problematically, remain. The article takes particular issue with the ongoing failure to listen to women’s experiences of maternity care: “Respectful care is an essential component not just of quality and safety but of basic human rights and dignity”. This is followed by a link to a video created by two women, Susanna Stanford and Sarah Seddon, who experienced adverse events in their peripartum care, and are now involved in patient safety advocacy. Please watch it. The third article looks at safety in paediatric anaesthesia, and recent efforts to quantify risk through large datasets. The data again raises the questions (still unanswered) of which children can safely be cared for in which type of hospital. While obstetric and paediatric anaesthesia are often regarded as being stressful, particularly by clinicians for whom they only for a minor part of their practice, further discomfort seems to arise when anaesthesiologists are asked to provide anaesthesia outside of the operating theatre. NORA (Non-Operating Room Anaesthesia) now accounts for up to 30% of all anaesthetics given in some institutions. Caoimhe Casby looks at the environmental, psychological, and patient factors that create a challenge to the delivery of safe care. Finally, following an enormously successful Green Week, Tim Keady provides a summary of the event and what we might take away from it. Many congratulations to everyone who was involved. Also, a reminder that the CAI annual patient safety conference – NAPSAC 5 – takes place on Friday, November 12th. It is a day of three parts. In order to mark the theme of WPSD, the first part of the morning will be a standalone session on safety in obstetric anaesthesia, with brief contributions from anaesthesiologists from five Colleges – Ireland, UK, Canada, Australia and New Zealand, and Hong Kong. The Winter College Lecture, which this year will be given by Martin Bromiley, will be the penultimate event, prior to the awarding of the KP Moore Medal. The draft programme of the day is set out on the last page.