Every minute around the world, at least five lives are lost due to unsafe health care. For Hisashi Katsumura from Japan, this is more than just a number.
Hisashi and his wife Rie were expecting their first child shortly after getting married in 1990. But two weeks before the due date, Rie was admitted to hospital where she was given a labour-inducing drug. “We were told only that it was used to soften the cervix,” explains Hisashi.
Without warning, the situation became dire. “Something went wrong. The doctor told me my child would not make it,” says Hisashi. “The hospital never explained what happened. It was only later that we learned the drug was administered to convenience the hospital’s schedule.”
Hisashi was left reeling from this tragedy. “My child died, but I thought her life could have meaning if the world changed and future accidents were prevented,” he explains. He became a committed advocate for improving patient safety policy in Japan.
Implementing WHO’s Global Patient Safety Action Plan
When it comes to patient safety, the majority of mistakes that lead to harm do not occur because of the actions of an individual health worker. Rather, they are due to system or process failures that lead to mistakes. That is why improving patient safety requires shifting from a traditional approach that focuses on blame to one that emphasizes system-based thinking. Health workers often operate in complex and rapidly changing environments. Errors can be avoided when robust systems and processes are designed to support their work and aid them in making sound decisions.
For stronger patient safety, health-care workers must be supported by robust systems and processes. Photo credit: WHO/Y. Shimizu
The World Health Organization (WHO) has developed the Global Patient Safety Action Plan 2021−2030: Towards eliminating avoidable harm in health care to provide a framework for action towards systemic change. The Plan works towards a world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere.
In the Western Pacific Region, WHO is working closely with Member States to implement the Plan by strengthening regulation and policies and improving monitoring of patient safety measures. Importantly, WHO and Member States are also working to better engage patients, families and communities in their own health care. This includes putting patients’ needs at the centre of care, making sure they understand the treatment being offered and obtaining proper consent. When Hisashi lost his child several decades ago, this last step was not part of the provision of care to patients. “Back then, the culture of health care was paternalistic,” he says. “Little importance was placed on informed consent for the patient.”
Hisashi became an advocate for patient safety after he and his wife lost their child when a drug was administered by the hospital during labour. Photo credit: WHO/J. Terauchi
Patient engagement is key
It is becoming increasingly clear that engaging patients in their own care is vital and effective. Studies have shown that meaningful patient engagement could result in a reduction in the burden of harm by up to 15%, saving countless lives and billions of dollars each year.
For Hisashi, a key issue is to ensure that patients have a clear understanding of the care they are receiving. “The first step was that patients are provided with statements clarifying the procedures and medications used during treatment,” he shares. He works with the legal system, medical councils and committees to move towards a health system where patients are empowered. He also works with the Ministry of Education, Culture, Sports, Science and Technology to ensure that all high school students in Japan study patient safety in their classes so that they are aware of the potential risk of health care and can be advocates for the patient safety in the future.
“I would like to see the next generation of children grow up informed about the medical system,” explains Hisashi. “I felt that this was an assignment given to me by my child to prevent similar tragedies by improving both hospital and health care.”
Hisashi works with the legal system, medical councils and Government to advocate for and educate the public about patient safety. Photo credit: WHO/J. Terauchi
From patients and families to policy-makers, health workers and patient organizations, all of society can work towards policies and safety measures that truly reflect the needs and preferences of patients. Learn more about how you too can contribute to patient safety here.
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