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Patient Safety Virtual Global Discussion  


March 1-12, 2010
http://hpgn.org/HPGN/patientsafety 

The purpose of the two-week forum is to share multi-professional experiences on patient safety and teamwork, share ideas on the development and proper use of a generic Patient Safety Curriculum Guide, and contribute to the revision of the World Health Organization’s Multi-Professional Patient Safety Curriculum Guide.


Discussion Statistics


Number of participants: 1,557
Number of participants' countries: 118
Number of contributions: 437
% of contributions from developing countries: 55%
Number of countries contributing: 50 countries

Contributing countries: Argentina, Australia, Canada, Chile, Colombia, Croatia, Denmark, Ecuador, Egypt, Ethiopia, Grenada, Georgia, Ghana, Greece, India, Italy, Iran, Iraq, Ireland, Jordan, Kenya, Kuwait, Lebanon, Malaysia, Mexico, Morocco, Netherlands, New Zealand, Nigeria, Norway, Oman, Pakistan, Peru, Philippines, Poland, Qatar, Saudi Arabia, Singapore, Slovenia, South Africa, Spain, Sudan , Sweden, Tanzania, Thailand, Turkey, Ukraine, United Arab Emeritus, United Kingdom, United States of America, Yemen


Purpose and Objectives

Purpose:

The purpose of the two-week forum is to share multi-professional experiences on patient safety and teamwork, share ideas on the development and proper use of a generic Patient Safety Curriculum Guide, and contribute to the revision of the World Health Organization’s Multi-Professional Patient Safety Curriculum Guide.

The first week of this global discussion (1 March – 5 March) will focus on sharing multi-professional experiences on patient safety and teamwork. During the second week of discussion (8 March – 14 March), we invite you to share ideas on the development and proper use of a generic Patient Safety Curriculum Guide.

                                                                                                                                
Day 1 : General patient safety issues

Questions:

  1. Is patient safety an essential issue to all health professions in the provision of quality health care? What is your experience?
  2. How do you think your own health profession can best be supported to provide safe care? Are there examples where this is already being done?

Day 1 Summary:

This has been a very active first day of discussion! 58 contributions were received from  Argentina, Egypt, Ethiopia, Georgia, India, Kuwait, Lebanon, Norway, Philippines, Poland, Saudi Arabia, Singapore, Slovenia, Thailand, UK, and USA. Many participants made general comments on patient safety in all health professions. Others discussed professional support necessary for ensuring patient safety and others described success stories and challenges they are facing.
              
Day 2 : Failures in the medical system 

Questions:

  1. Have you encountered situations where failures in the medical system harmed health care workers in addition to harming patients?
  2. If you made a serious error while caring for a patient, what would you want a colleague to say to you about it?

Day 2 Summary:

The discussion remains very active with 48 contributions from Australia, Colombia, Egypt, Grenada, India, Kenya, Mexico, Morocco, Netherlands, New Zealand, Philippines, Qatar, Saudi Arabia, Spain, Sudan, Thailand, Ukraine, UK, USA, and Yemen. Some participants discussed patient safety in a multi-professional setting. Many participants described success stories and challenges they are facing.
              
Day 3 : Health care-associated infections

Questions:

  1. Is enough being done to support the sustained reduction of health care-associated infections by all health-care professionals around the world?
  2. The information on hand hygiene and infection control in the Patient Safety Curriculum Guide should help broaden the reach of such technical content. In an attempt to continue to enhance a safety culture within all health-care settings the team of WHO Clean Care is Safer Care programme is eager to hear about innovative ways in which hand hygiene and other infection control measures are being encouraged, adopted and sustained. What success can you demonstrate in this regard?

Day 3 Summary:

This discussion continues to remain incredibly active with 88 contributions from Argentina, Australia, Chile, Colombia, Croatia, Egypt, Georgia, Grenada, Greece, India, Italy, Kenya, Kuwait, Malaysia, Norway, Oman, Pakistan, Saudi Arabia, Singapore, Spain, UAE, United States of America, UK, United Kingdom of Great Britain and Northern Ireland, and Yemen.

Today we continued to discuss patient safety in a multi-professional setting and began sharing experiences. Today’s discussion focused on sharing failures in medical systems as well as dealing with errors on an emotional level.

              
Day 4 : Health care-associated infections continued

Questions:

  1. Is enough being done to support the sustained reduction of health care-associated infections by all health-care professionals around the world?
  2. The information on hand hygiene and infection control in the Patient Safety Curriculum Guide should help broaden the reach of such technical content. In an attempt to continue to enhance a safety culture within all health-care settings the team of WHO Clean Care is Safer Care programme is eager to hear about innovative ways in which hand hygiene and other infection control measures are being encouraged, adopted and sustained. What success can you demonstrate in this regard?

Day 2 Summary:

: We continue to have a very active, thought provoking dialogue with 52 contributions from: Australia, Canada, Ecuador, Egypt, Ethiopia, India, Iraq, Ireland, Kenya, Kuwait, Malaysia, Nigeria, Oman, Qatar, Sweden, Thailand, Ukraine, UK, and the USA.

Today we released the draft version of the Topic 9 of the WHO Patient Safety Curriculum Guide (Multi-professional). Additionally, we began discussing infection control and hand hygiene. The community unanimously agreed that not enough was being done to support the sustained reduction of health care-associated infections by all health-care professionals around the world.
Overall it was clear that people felt there is urgency for action to reduce hospital acquired infection (HAI) burden and that what is currently being done may be inadequate and disjointed.

              
Day 5 : Health care-associated infections continued 

Questions:

  1. Is enough being done to support the sustained reduction of health care-associated infections by all health-care professionals around the world?
  2. The information on hand hygiene and infection control in the Patient Safety Curriculum Guide should help broaden the reach of such technical content. In an attempt to continue to enhance a safety culture within all health-care settings the team of WHO Clean Care is Safer Care programme is eager to hear about innovative ways in which hand hygiene and other infection control measures are being encouraged, adopted and sustained. What success can you demonstrate in this regard?

Day 5 Summary:

We had 39 contributions today from Argentina, Colombia, Croatia, Egypt, Georgia, Greece, India, Iran, Iraq, Ireland, Kenya, Iran, Peru, Philippines, Qatar, Saudi Arabia, Slovenia, South Africa, UK, USA and Yemen.

Today we continued discussing infection control and hand hygiene as well as reviewed the draft of the Topic 9: Patient Safety Curriculum Guide (Multi-professional).


              
Day 6 : Teamwork and patient safety

Questions:

  1. Have you encountered situations where teamwork failures in your health-care system harmed patients?
  2. What barriers to effective teamwork have encountered in your health-care environment. Do you have any examples of how these can be overcome?

Day 6 Summary:

Today we had 30 contributions from Argentina, Australia, Egypt, Ethiopia, Georgia, India, Iraq, Ireland, Jordan, Malaysia, Morocco, Oman, Pakistan, Saudi Arabia, Singapore, Tanzania, Turkey, Ukraine, UK, USA, and Yemen! Today we began discussing teamwork as it relates to patient safety. Participants discussed failures of teamwork in health care systems leading to patient harm, barriers to effective teamwork, and overcoming barriers. Other participants discussed teamwork success stories.             
Day 7 : Teamwork and patient safety continued 

Questions:

  1. Have you encountered situations where teamwork failures in your health-care system harmed patients?
  2. What barriers to effective teamwork have encountered in your health-care environment. Do you have any examples of how these can be overcome?

Day 7 Summary:

Today we received 12 contributions from Colombia, India, Ireland, Mexico, Morocco, and USA. We continued to discuss teamwork in regard to patient safety. Participants discussed the same topics as yesterday – failures of teamwork in health care systems leading to patient harm, barriers to effective teamwork, and overcoming barriers. In addition, some participants discussed innovations in hand hygiene.
              
Day  8: Teaching patient safety

Questions:

  1. Is patient safety being adequately taught to students, and are you aware of any variations between different healthcare areas?
  2. Do you think there are specific challenges to teaching the generic patient safety curriculum to students in the developing world?

Day 8 Summary:

Today we had 39 contributions from Australia, Canada, Denmark, Egypt, India, Ireland, Iraq, Lebanon, Malaysia, Morocco, Nigeria, Oman, Pakistan, Saudi Arabia, Singapore, Spain, Sudan, Thailand, UK, USA, and Yemen. Some participants discussed patient safety in healthcare provider curricula. The overwhelming majority of contributors felt as though patient safety was not being adequately taught to students. Other talked about teaching patient safety issues in different healthcare areas, such as nursing and medical schools. Others discussed the hierarchy of health care providers as a major barrier in developing countries. Still others provided success stories of teaching patient safety.
              
Day  9: Including non-acute hospital-based practitioners in patient safety

Questions:

  1. Do we sufficiently emphasize the importance of admission and discharge information being transmitted to and from community-based practitioners and acute hospitals that provide emergency care? Can you give examples from your own practice of where this has been a problem?
  2. How could we develop the Patient Safety Curriculum Guide, for example though the concept of teamwork and team, to extend the work of the team to include non-acute hospital based practitioners?

Day 9 Summary:

Today we received 22 contributions from Australia, Italy, UK, Egypt, Saudi Arabia, Pakistan, Malaysia, India, United States of America, Ukraine, Ghana, México, Indonesia, Peru, Ireland.

There is a general consensus that there is not enough emphasis on the importance of transmission of admission and discharge documentation and that it remains a problem. Many examples were given where the lack of transmission of admission and discharge documentation to and from community-based practitioners and hospitals created problems. Other participants provided suggestions on how to include non-acute hospital based practitioners in the work of the patient safety team.

              
Day  10: Challenges in advocating for the inclusion of patient safety in health professions’ curricula

Questions:

  1. What are the main obstacles or challenges you have encountered – or foresee to encounter – as we advocate for the inclusion of patient safety into our health professions’ curricula?
  2. What specific advocacy methods and strategies would you suggest in order to overcome these obstacles/challenges? Have you been involved in any successful examples of this?

Day 10 Summary:

Welcome to the final digest of the Patient Safety Virtual Global Discussion Forum! Over the weekend we received 42 contributions from Argentina, Egypt, Ghana, India, Kenya, Kuwait, Peru, Saudi Arabia, Singapore, Slovenia, Ukraine, USA, and Yemen. The weekend’s discussion was focused on obstacles to including patient safety in the curriculum as well as the sharing of advocacy and strategy methods. Several contributors encouraged lobbying with both nursing boards and medical councils about patient stafety. Others provided success stories.
              
Post-forum survey results

Number of surveys completed 203

% who have passed content to others 44%

% who have or will use in their work  44%

% very satisfied with forum content 60%

Suggestions for improvement :  

  • Increase length of discussion days for each topic so that more members have a chance to contribute.
  • Continue discussions into the future to create a basis for global networking.
  • Establish specific goals for each discussion and publish a checklist to send to participants before each discussion with the points or issues that each commentary must include.
  • More guided questions to focus participants on answers.
  • Group postings that address the same issues into a database and make that accessible in the library.
References and resources
Click here for related resources and references in the community library




Organizing groups

World Health Organization, Department of Reproductive Health and Research (WHO/RHR), World Health Organization Patient Safety Curriculum Guide team

Contributing experts/facilitators 

Professor Merrilyn Walton, University of Sydney, Australia

Professor Albert Wu, Johns Hopkins University, USA

Claire Kilpatrick, WHO Patient Safety, Switzerland

Dr. Geeta Metha, WHO South East Asia Regional Office, India

Dr. Amitai Ziv, The Israel Centre for Medical Simulation, Sheba Medical Center and Sackler School of Medicine, Israel

Professor Rhona Flin, School of Psychology, University of Aberdeen, UK

Professor Raman Bedi, Kings College London, UK

Professor Lesley Barclay, University of Sydney, Australia

Dr. Anas Eid, Zakah Hospital, Palestinian Territory, former President of International Federation of Medical Students Associations, France

Dr. Armando Crisostomo, Philippine College of Surgeons, Philippines

Moderators 

Christina Fusco, World Health Organization Sophie Berlamont, World Health Organization