A global challenge to reduce harm and save lives
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A global challenge to reduce harm and save lives



Apresentação de Itziar Larizgoitia Jauregui durante o ...

Apresentação de Itziar Larizgoitia Jauregui durante o
Itziar Larizgoitia Jauregui é médica, nascida na Espanha, com atuação em Saúde Pública, com mestrado nessa área e Doutorado em Políticas e Gestão da Saúde. Nos últimos 13 anos, tem atuado como membro da Organização Mundial da Saúde (OMS) em Genebra, Suíça. No total, são mais de 20 anos de experiência nas áreas de Qualidade e Segurança do Paciente, Organização e Reforma de sistemas de saúde.



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    A global challenge to reduce harm and save lives A global challenge to reduce harm and save lives Presentation Transcript

    • A global challenge to reduce harm and save lives Implementation and Scale Up of Patient Safety Programs Dr Itziar Larizgoitia WHO Patient Safety Programme Symposium Einstein- IHI 2013
    • The burden of unsafe care is widespread and higher than expected
    • Patient Safety: A global challenge • 42.7 million adverse events. These adverse events result in 23 million DALYs lost per year. • Approximately two-thirds of all adverse events, and the DALYs lost from them, occurred in low income and middle-income countries • Given the magnitude of these effects, findings suggest that to improve the health of the world’s citizens, we will need to improve access to care and also to invest substantial focus on improving the safety of the healthcare systems that people access worldwide Jha AK, et al. BMJ Qual Saf 2013;22:809–815.
    • Global resources devoted to patient safety should be concentrated in LMICs, where the burden is greatest Jha AK, et al. BMJ Qual Saf 2013;22:809–815.
    • Deaths associated to preventable harm…………………………..210 000 John T. James, J Patient Saf 2013;9: 122Y128
    • Healthcare can not be dissociated from interventions to improve its safety
    • ** Incidence Average in Europe: 7.1% patients ECDC, Comm Dis Report 2008 Prevalence of HAI in developed countries
    • Prevalence of Healthcare Associated Infections in transitional & developing countries Pooled prevalence 15.5% patients Lancet, 2011; 377: 228–41
    • Unsafe injection practices: A plague of many health systems ■ Over-prescription of injections • In some situations, 9 out of 10 patients presenting to a primary healthcare provider receive an injection, over 70% of which are unnecessary or could be substituted by oral medications ■ Reuse of syringes and needles in the absence of sterilization exposes millions of people to infections ■ Each year unsafe injections cause an estimated 1.3 million early deaths, a loss of 26 million years of life, and an annual burden of USD 535 million in direct medical costs.
    • IBEAS: A study on 5 Latin-American Countries. And, 2 out 10 suffered an incident during their hospital stay On average, on the day of the survey, 1 in 10 inpatients showed the consequences of a patient safety incident Death Permanent Disability Low Disability Moderate Disability Argentina Perú Colombia Costa Rica México
    • Universal health coverage is our new priority “I regard universal health coverage as the single most powerful concept that public health has to offer. It is inclusive. It unifies services and delivers them in a comprehensive and integrated way, based on primary health care" Dr Margaret Chan, WHO Director-General
    • WHO's call for Universal Health Coverage "To free the world from extreme poverty by 2030, countries must ensure that all their citizens have access to quality, affordable health services" Margaret Chan, WHO Director General Expanding access to healthcare should be accompanied by activities in quality and patient safety improvement.
    • Areas of intervention
    • Putting safety on the world's agenda
    • First Global Patient Safety Challenge Clean Care is Safer Care WHO Guidelines for Hand Hygiene in Health Care
    • WHO Surgical Safety Checklist Safe Surgery Saves Lives
    • Fostering a global patient-led movement to encourage partnership, promote empowerment and inspire action on patient safety around the world.
    • Effective solutions imply tackling the latent organizational weaknesses and failures
    • The burden of unsafe care: Global Priority areas ■ Counterfeit and substandard drugs ■ Problems with communication and coordination ■ Latent organizational failures ■ Inadequate competence, training and skills ■ Maternal and New Born Care ■ Unsafe Injection and Blood Practices ■ Poor Safety Culture ■ Lack of Human Factors design ■ Misdiagnosis ■ Insufficient cost-effective risk-reduction strategies
    • Improving patient safety through effective interventions ■ By Creating and Sustaining a Culture of Safety ■ Through Informed Consent, Life-Sustaining Treatment, Disclosure, and Care of the Caregiver ■ By Matching Healthcare Needs with Service Delivery Capability ■ By Facilitating Information Transfer and Clear Communication ■ Through Medication Management ■ Through the Prevention of Healthcare-Associated Infections ■ Through Condition- and Site-Specific Practices ■ Opportunities for Patient and Family Involvement Safe Practices for Better Healthcare–2010 Update: A Consensus Report - National Quality Forum
    • Expand Education of the workforce
    • WHO Patient Safety Curriculum Guide Multi-professional edition
    • Curso online: Introdução à investigação sobre segurança do paciente/doente – The sessions Sessão 1: Segurança do Paciente/Doente, o que é?, Claudia Travassos, 1°de março de 2012 Sessão 2: Princípios da investigação em segurança do paciente/doente, Mônica Martins, 8 de março de 2012 Sessão 3: Medir o dano, Walter Mendes, 15 de março de 2012 Sessão 4: Compreender as causas, Walter Mendes, 22 de março de 2012 Sessão 5: Identificar as soluções / Implementação, Maria João Lage, 19 de abril de 2012 Sessão 6: Avaliar o impacto, Paulo Sousa, 26 de abril de 2012 Sessão 7: Transpor a evidência em cuidados mais seguros, José Fragata, 3 de maio de 2012 Sessão 8: Aprofundar o conhecimento em segurança do paciente,Paulo Sousa, 10 de maio 2012
    • Engaging professionals and engineering systems for safety
    • Launch of a Global Campaign on Medication Safety The 3rd Global Challenge on Patient Safety 2014-2015
    • Safe Injections Campaign Behaviour change strategies to reduce overuse of injections Implementation of a sound sharps waste management option to prevent scavenging and reuse of syringes Continuous availability of safety engineered injection devices to prevent reuse and stick injuries
    • Addressing the challenges of implementation
    • Challenges to implementation: no magic bullet ■ Consistent use, of interventions are not straightforward in any setting. It may be more difficult in low-income countries ■ Resources and changes to clinical systems may be needed to secure compliance ■ Wrong implementation may cause additional unintended risks in low- income settings Emma-Louise Aveling, Peter McCulloch, Mary Dixon-Woods. BMJOpen 2013;3:e003039.
    • Eliminating Bacteremia in ICU's • Educate • Engage • Execute • Evaluate 1. Adequate Hand Hygiene 2. Skin disinfection with clorhexidine 3. Extreme hygiene barriers in insertion 4. Removal of unnecessary lines 5. Hygienic maintenance of lines 1. Assess patient safety culture 2. Training in patient safety principles 3. Identify falleres in standard practice 4. Set up alliances with management 5. Learn from mistakes STOP-BACTERAEMIA Comprehensive Safety ICU programme 32
    • Palomar et al Critical Care Medicine DOI: 10.1097/CCM.0b013e3182923622 Major discriminant factor: understanding of patient safety principles and tools Those who shared the principles of patient safety, were sensitive to their leadership, team work and engagement
    • Patient safety culture is the single most relevant condition for successful implementation
    • Implementation ■ Culture ■ Leadership at all levels, including authorities for successful scale up ■ Educate ■ Engage professionals and teams: foster team building and integration ■ Execute: Fixing the system, engineering processes for safety ■ Evaluate and provide feedback
    • WHO invites Member States, healthcare professionals, academics, patients and citizens to: - Foster the patient safety culture - Adopt effective solutions - Roll out commitment & engagement To achieve Universal Health Coverage of safe and quality care
    • Thank you www.who.int/patientsafety/en