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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 3-11

1999–2019: Twenty years of watershed moments for patient safety

1 Saudi Patient Safety Center, Riyadh, KSA
2 Saudi Critical Care Society, Former President, Co-Founder and Board Member

Date of Web Publication30-May-2019

Correspondence Address:
Yasser Mandourah
Saudi Critical Care Society, Former President, Co-Founder and Board Member

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2543-1854.259479

Rights and Permissions

The case for patient safety is obvious; no one would argue in favor of harming patients. Since the launch of the paper To Err is Human, patient safety has been on the forefront of public health policymakers' priorities. Yet, 20 years later, while progress has been made, harm to patients is still a reality, daily, in health systems over the world. As countries reform their health systems, the national health programs must ensure not only the integration of universal health coverage (UHC) but also that the health coverage provided is safe. To this point, new models of care must be designed and implemented, and organizations should aim to achieve high-reliability care, similar to other industries that keep a solid safety record. This can be achieved by aiming for high-reliability organization principles, ensuring empowerment of patients as codesigners of health care, workforce safety to ensure safety of patients, and UHC without harm and proper regulation of digital health to avoid unintended adverse consequences. Since the past 20 years, the knowledge gap on patient safety has been shortened and therefore the health-care community holds a firm foundation for starting to implement evidence-based strategies that ensure safe care. The Jeddah Declaration on Patient Safety, 2019, is an actionable document that provides guidance to policy- and decision-makers globally that aim to achieve UHC free of harm. Nevertheless, given the high-level of complexity of health-care systems and its vulnerability to error, the question is what is the way forward toward a safer provision of care? How can the year 2019 be the watershed moment for the health-care industry?

How to cite this article:
Macedo M S, Mandourah Y, Moore A, AlHawsawi A. 1999–2019: Twenty years of watershed moments for patient safety. Saudi Crit Care J 2019;3:3-11

How to cite this URL:
Macedo M S, Mandourah Y, Moore A, AlHawsawi A. 1999–2019: Twenty years of watershed moments for patient safety. Saudi Crit Care J [serial online] 2019 [cited 2023 Jun 4];3:3-11. Available from: https://www.sccj-sa.org/text.asp?2019/3/1/3/259479

  Introduction Top

The case for patient safety is obvious; no one would argue in favor of harming patients. The principle “ first do no harm” is the fundamental cornerstone to the provision of high-quality health care. The landmark paper To Err is Human, brought to light in 1999, has become the main watershed of the global patient safety movement, and, since then, patient safety has been on the forefront of public health policymakers' priorities. Yet, 20 years later, while progress has been made, harm to patients is still a reality, daily, in health systems over the world.

The stories presented throughout this paper are just an example among the (estimated) 64 million disability-adjusted life years that are lost in the world, annually, because of unsafe care, bringing patient harm related to adverse events as one of the top ten leading causes of death and disability in the world.[1] This is comparable to tuberculosis and malaria global disease burden, raising patient harm as a true global public health concern.[2]

Moreover, evidence suggests that 134 million adverse events occur in low- and middle-income countries' (LMICs) hospitals, contributing to 2.6 million deaths.[3] In high-income countries, approximately 1 in 10 patients is harmed while receiving medical care[3] and about two-thirds of the global burden of adverse events occurs in LMIC.[3]

In the US, medical errors are the third leading cause of death, resulting in more than 251.000 deaths annually. In England, 3.6% of deaths in acute hospitals occur due to wrong provision of care, while one incident of patient harm is reported every 35 s.

The global landscape of health care is changing, and today, health-care systems find themselves operating in a highly volatile, complex environment. While ongoing technological advancements, new treatments, and new care delivery models can have therapeutic potential, they can also generate new risks for error with high potential to harming patients and thus becoming a threat to safe provision of care.[4]

Two decades of global efforts to reduce the burden of patient harm have not achieved considerable change, and safety measures implemented by high-income countries have had limited impact or have not been shaped for successful implementation in LMIC.[4]

Given the high-level of complexity of health-care systems and its vulnerability to error, the question is what is the way forward toward a safer provision of care? How can the year 2019, 20 years after the first report was launched, be the watershed moment for the health-care industry?

  Universal Health Coverage and Economics of Patient Safety Top

As countries reform their health-care systems, for example, Saudi Arabia, structures and processes are being put in place to ensure the integration of universal health coverage (UHC) into their national transformation programs, in an effort to expand coverage to all population groups.

However, the benefits of increased access to health care may be undermined by service structures, cultures, and/or behaviors that inadvertently harm patients and may lead to fatal consequences.[4] Although access is a necessary condition for achieving high-quality care, it does not guarantee quality in no way. While planning health-care systems that envision UHC, decision-makers and policymakers must assure that they are not endorsing over flawed and wasteful models of care. UHC is to be delivered while reassuring the population that they can trust their health-care systems to keep them and their families safe.

Adverse events can occur at any point of patient's care pathway: primary care, hospital care, or long-term care. The type of adverse event varies between settings, but similar causative factors can be attributed to many types of harm. These relate to communication failures, absence of relevant information, insufficient education, knowledge and skills, and inadequate organizational culture.[3]

The financial impact of safety failure to patients, health-care systems, and societies is considerable. A lack of focus on patient safety has major financial implications for both high-income countries and LMICs. Overall, 15% (conservative figure) of hospital expenditure and activity in OECD countries can be attributed to treating safety failures. Poor-quality care imposes costs of US$ 1.4 trillion to 1.6 trillion each year in lost productivity in LMICs where most of the burden is associated with a few common adverse events. The most burdensome diseases include health-care-associated infections (HAIs), venous thromboembolism (VTE), pressure ulcers, medication error, and wrong or delayed diagnosis.

Overall, the sound and systematic implementation of patient engagement strategies and health literacy programs could reduce aggregate harm by up to 15%, which would constitute a very good return on investment. At the political level, the cost of safety failure includes loss of trust in the health systems, governments, and social institutions.


  1. Integration of patient safety as an essential requirement of UHC without harm, at all levels of care (primary, secondary, and tertiary)
  2. Greater investment in the prevention of avoidable medical errors is crucial. Many adverse events can be systematically prevented through better policy and practice, with the cost of prevention typically much lower than the cost of harm. Investing in patient safety programs will enable Saudi Arabia to save, in a period of 5 years, the equivalent of SAR 105 billion (extrapolated figure). A national value-based approach, where harm is reduced using limited resources, should begin with investing in fundamental system-level initiatives such as professional education and training, safety standards, and a solid information infrastructure
  3. It is important to encourage countries throughout the world, to work closely with LMIC to promote patient safety in these countries[5]
  4. As part of its contribution to the pressing global health demands, the Kingdom of Saudi Arabia has committed to a patient safety outreach initiative to promote safety and work on setting patient safety research priorities with special emphasis in LMIC
  5. Higher level of support to implementation and sustainable scale-up of patient safety interventions of known efficacy/effectiveness at national and global level.[5]

High-Reliability Organizations and Patient Safety

Disasters are inevitable, resulting in fatality, loss, and permanent damage, and with each unfortunate occurrence, precautions, safety measures, and changes are applied globally in each sector and industry. On March 27, 1977, two Boeing 747 passenger jets, KLM Flight 4805 and Pan Am Flight 1736, crashed on the runway, resulting in the loss of nearly 600 lives. The crash was mainly caused by the lack of standard phraseology and radio communications. The infamous Chernobyl nuclear reactor accident took place in April 1996. It was the result of a flawed reactor design that was operated by inadequately trained personnel. The accident is estimated to have caused 4000 deaths directly related to radiation exposure. Piper Alpha was a North Sea oil and gas production platform. On July 1988, due to a gas explosion, the platform was completely destroyed and 167 lost their lives with many more injured and traumatized. The accident was caused by a bad managerial decision to resume production despite all warnings.

While these seemingly unrelated disasters were unfortunate, they have one thing in common: they were totally avoidable. A precious lesson was to be learned from these catastrophes and so all leading industries have reviewed their processes and introduced a new set of rules and guidelines that would avoid future disasters. Few years ago, these industries were not as safe as they are today. Having gone through these watershed moments, they have learned valuable lessons and safety was transformed and today there is roughly 1 in a million chance of a person being harmed while traveling by an airplane compared to a 1 in 300 chance of a patient being harmed while receiving health care.[6] Industries with a perceived higher risk such as the aviation and nuclear industries have a much better safety record than health care.

As the health-care industry sets its target to improve patient care outcomes and thus safety of care results, it becomes clear that this industry needs to invest more resources and effort to catch up to other consumer-based industries with solid track record in implementing high-reliability organization (HRO) model.[7] The HRO model is a mission critical for clinics and physician-based practices to address the current health-care needs and anticipated future requirements.[8] Achieving consistent and reliable patient care outcomes and sustainable business performance results should be a shared vision and a common target.[7]

The question always comes up is, why the health-care delivery system is not as reliable and safe as other industries?

Despite several high-profile airline accidents, the year 2014 turned out to be a very safe year for commercial aviation, according to recently published aviation safety data. Given the expected worldwide air traffic of 33,000,000 flights a year, the accident rate is one fatal passenger flight accident per 4125,000 flights.[9] Obviously, the difference in reliability outcomes between the two industries is significant, and it should force health-care organizations and their leaders to consider what types of evidence-based models and strategies to use to address critical health-care issues.

Implementing a HRO model is essential to address complex health-care environments.

An HRO model is an environment of “collective mindfulness” where all caregivers, employees, management, and key stakeholders look for, and report, small problems or unsafe conditions before they pose a substantial risk to their patients and when they are easy and affordable to fix. These organizations rarely, if ever, have significant accidents. They prize the identification of errors and close calls for the lessons they can extract from a careful analysis of what occurred before these events. They are characterized by preoccupations with failure, reluctance to simplify, sensitivity to operations, commitment to organization resilience, and deference to qualified and relevant expertise.

Implementation of HRO model in health care has proven to improve organizational effectiveness, organizational efficiency, customer satisfaction, compliance, documentation, and organizational culture.[10]

The case calling for the health-care industry to embrace HRO model and innovation is more urgent than ever was. The question is, in health care, what is our watershed moment, or moments? How can we learn and have an equivalent safety transformation? Can the year 2019 be that watershed moment for patient safety?


  1. Integrate practical approaches to safety developed by non-health-care industries (aviation, oil and gas, nuclear, and transportation) into provision of care

  2. According to the Jeddah Declaration on Patient Safety (Statement No. 7),[5] countries must learn from best practices in safety from other industries (aviation, nuclear, oil/gas, aerospace, and auto). The Saudi Patient Safety Center is launching a safety collaborative, which includes safety experts from various industries (health care and others) to work on win–win collaborations for collective safety improvement in all sectors[5]
  3. The implementation of HRO model must be mission critical for the health-care organization, and it must be led by the CEO, who is the primary stakeholder who can drive the necessary change mandate across an organization.[11]

  Patient Empowerment and Patient Safety Top

Patient safety is at the core of the health-care system, and the key challenge is to make sure that patients can take ownership of their condition.

Patients, families, and communities are the coproducers of health. They have a central role in ensuring people-centered care. Engaging patients, families, and caregivers is a key to the provision of safe care. Action must be taken to empower them and build their capacities as informed and knowledgeable health-care partners.

Health-care organizations should provide a platform to ensure that the voice of patients is heard in shaping policy design and implementation processes, and to foster collaboration among patients, families, communities, health-care providers and policymakers. Public campaigns should be promoted as a way to increase people's awareness of their roles in ensuring safe care, as well as their rights to receive such care as safe care and protection from harm should be the right of every individual treated in a health-care system.[4]

Patient empowerment efforts in improving the culture of safety have focused on three areas:

  • Enlisting patients in detecting adverse events
  • Empowering patients to ensure safe care
  • Emphasizing patient involvement, to promote patient-centered health care.[12]

It is also well known that critical care patients and their next of kin often experience powerlessness, vulnerability, anxiety, and stress.[13]

Patient empowerment is a process that helps people gain control over their own lives and increases their capacity, to become stronger and more confident to act on issues that they themselves define as important. Empowerment as an action refers both to the process of self-empowerment and to professional support of people, which enables them to overcome their sense of powerlessness and lack of influence and to recognize and use their resources.

According to Walker and Avant, the defined attributes of empowerment in critical care were found to be related to what happens both between individuals and within an individual: a supportive relationship, knowledge, skills, power within oneself, and self-determination. For example, when patients and next of kin were provided with information and explanation, it leads to an awareness of the situation and a sense of coherence.[14]

The next of kin could feel empowered, for example, when receiving help in developing skills that enable them to participate in care. Critical care patients and next of kin experience power within oneself, which could be described as a fighting spirit or self-efficacy/self-esteem, when recognized, accepted, and respected as an individual and for one's way of thinking.[15] Being heard and acknowledged means that one's experience is facilitated and encouraged, which confirms one's worth.[16] Patient empowerment includes having possibilities. This could include, for example, entrusting the care to health professionals, sharing decisions, or making an informed choice.

Therefore, the benefits of improving patient and family empowerment are extensive: decreased levels of distress and strain, increased sense of coherence and control over situation, and personal and/or professional development and growth, together with increased comfort and inner satisfaction.

In addition, informed patients are more likely to feel confident to report both positive and negative experiences and have increased concordance with mutually agreed care management plans. This not only improves health outcomes but also advances learning and improvement, while reducing adverse events.


  1. Develop national patient safety strategies following effective consultation with citizens, patients and their families, health-care staff, system leaders, and providers, while promoting health literacy for effective decision-making
  2. According to the Jeddah Declaration on Patient Safety (Statement No. 3),[5] organizations must promote patient empowerment and community engagement for patient safety by encouraging countries to adopt practical empowerment strategies for patients and families. Such strategies would highlight the principles of coproduction, for example, through strengthening health literacy and endorsing, implementing, and reinforcing patient-centered root cause analysis.

  Health-Care Workforce and Patient Safety Top

Safe high-quality health care requires skilled health-care workers. The health-care sector must make a fundamental shift to equate worker safety with patient safety. Health workers are integral to building strong and resilient health systems that contribute to the achievement of a UHC without harm, and thus, if the staffing levels and work environments are not safe for the health-care providers, they will not be safe for the patients.[17]

Health care is a high-risk, high-demand, high-stress industry in perpetual change, one with unique health and safety challenges. It operates 24/7/365 and much of the time is involved in matters of life and death. Nurses, who make up 77% of health workers, are on average 46 years old or older. Like other health workers, they work in fast-paced environments which have high physical work demands and require constant mental astuteness to oversee the needs of fragile, complex, compromised, very ill people, often in unpredictable settings.[18]

The available evidence that links the impact of poor nursing staffing and suboptimal patient safety-related outcomes is overwhelming. One study of particular significance was conducted by Aiken et al. at the University of Pennsylvania in 1994, which reported that hospitals that were able to retain nurses with lower turnover rates presented significantly lower mortality rates. This finding highlighted the likely impact of nursing practice environment on critical patient outcomes. Since then, the evidence that demonstrates the relationship between nurse staffing and patient outcomes continues to grow. Most recently, a 2017 study (Lee et al.) reported that, among the 845 patients analyzed, 95% were more likely to survive when nurses followed a hospital-mandated patient–nurse ratio. This supports the hypothesis that higher patient–nursing staffing ratios were related to decreased survival rate.

In addition, a study conducted by Tourangeau et al. (2002) highlighted the relationship between lower 30-day mortality and two predictors: a richer registered nurse (RN) skill-mix and more years of experience on the clinical unit. These findings reflect the effects of hospital changes in nursing skill mix and years of RN experience on patient mortality.

In view of this, several entities that promote and regulate high-levels of quality of care and patient safety have recognized how crucial adequate nursing staff levels are for ensuring safety in the delivery of care, and to this point, standards of care have been developed to enforce minimal nursing staff ratios. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2003) clearly states that if the staffing levels and work environments are not safe for the nurses, they will not be safe for the patients. The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI, 2016) mandates that sufficient nurses must be available to meet the needs of patients, where an evidence-based estimation of the number of staff needed per shift is in place considering all relevant factors (e.g., patient acuity, patient care hours, size of the hospital, and scope of services provided). Moreover, it mandates that nursing staff are allocated according to the skill level, qualifications, patients' volume and acuity, and in accordance with laws and regulations and nursing licensing boards.

Furthermore, hospitals that apply for Magnet® designation-where Magnet® is the “gold standard” for nursing excellence for which the main focus is to create a culture that has the best patient outcomes and the best work environment-states that charge nurses should be allowed to set the staffing levels on their floors determined by what nurses feel they can safely handle; and filled staffing should be filled by an appropriate mix of nurses based on experience and expertise, where the basic minimum nurse-to-patient ratios should be set no higher than those set by the current California legislation (AB 394 establishes specific numerical nurse-to-patient ratios for acute care, acute psychiatric, and specialty hospitals in California, where the ratios are the maximum number of patients that may be assigned to an RN during one shift.).

Impact on critical care

In a recent publication by Aiken et al. (2018), it has been reported that higher labor costs in hospitals with more nurses were offset by reduced intensive care use (<40%) and shorter length of stay.

In addition, hospitals with the best nurse staffing had 30% fewer hospital-acquired infections than hospitals with poor nurse staffing after considering patient risk factors and characteristics of hospitals such as size, technology, and teaching status.

Equally important to the investment on proper staffing numbers is the need for better investments in competent health-care professionals. Patient safety concepts and principles should become an indispensable part of clinical training, education, and continuous professional development for all categories of health-care professionals. Educational institutions are urged to adapt their institutional setup and modalities of instruction, so that they are aligned with national accreditation systems and population health needs, and to train health workers in sufficient quantity, quality, and with relevant skills, while integrating patient safety principles throughout their undergraduate curriculum as well as in continuing professional development programs.


  1. According to the Jeddah Declaration on Patient Safety (Statement No. 6),[5] health-care systems should invest on workforce knowledge and safety as the drivers for patient safety. Workforce safety (physical and psychological) is paramount to patient safety. Hence, it is important that countries adopt national policies addressing the following:

    • Second victims: to be supported by relevant departments within hospitals (health-care facilities)
    • Appropriate nursing staffing and skill mix in hospitals
    • Undergraduate curriculum for medical, nursing, dental, and allied health sciences (and related) degrees to include a patient safety and improvement science embedded curriculum. Using innovative approaches for training of health professionals such as interprofessional education.

  2. Establish national evidence-based health-care workforce staffing ratios and skill mix (ICN-SPSC White Paper) to ensure safe provision of care for patients and health-care professionals (second victim programs).

  Digital Health and Patient Safety Top

Application of digital technologies is indispensable in the 21st century for implementing patient safety interventions and monitoring and measuring their impact. In an era in which health-care delivery systems are becoming increasingly complex, digital technology can help support and enhance critical elements of patient safety, including incident reporting and the analysis of such reports to derive the lessons learned, monitoring of patient safety interventions, education and training of health-care professionals, patient and family engagement, and organizational learning.[4]

In addition, the ready availability of information on the extent, types and causes of errors, adverse events, and near misses is central to the development and implementation of patient safety policies, strategies, and plans. Hence, establishment of reporting and learning systems on adverse events should be given a special priority among other interventions to address patient safety. The reporting environment should be open, fair, blame-free, and nonpunitive to encourage health-care professionals to report and learn from incidents and to provide an opportunity for patients, their families, and caregivers to report on their experiences.

While the health-care community believes that health systems need to embrace new digital care technologies, from medical apps, patient engagement, big data, etc., making it more efficient and effective, the reality is that some digital systems cause problems, both for patients and for staff, sometimes leading to patient harm. Alongside benefits, digital health can pose risks to patient safety. It is widely believed that health IT, when designed, implemented, and used appropriately, can be a positive enabler to transform the way care is delivered. Designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care, which can lead to unintended adverse consequences, for example, dosing errors, failure to detect fatal illnesses, and delayed treatment due to poor human–computer interactions or loss of data. The user interface is one of the most important factors influencing the willingness of clinicians to interact with electronic health records and to follow the intended use that is assumed to promote safe habits. The more functional the user interface, the more it enhances usability of the product. Inadequate user interfaces can lead to error and failure.[19]

Software-related safety issues are often attributed to software coding errors or human errors while using the software. However, many problems with digital health relate to usability, implementation, and how software fits with clinical workflow. Focusing on coding or human errors often leads to neglect of other factors (e.g., usability, workflow, and interoperability) that may increase the likelihood a patient safety event will occur. Digital health is neither safe nor unsafe because safety of health IT cannot exist in isolation from its context of use. Safety considers not only the software but also how it is used by clinicians. Understanding this relationship is crucial to ensure correct usage of digital solutions as it is important to avoid inappropriate blame of users.

Problems with information technology can disrupt care delivery and introduce new clinical errors that can harm patients, and safety risks become a side effect or unintended consequence of IT. The problems are worse when the digital causes are not understood and may result in inappropriate blame.

Current health IT products are still improving their capacity to increase communications and reduce errors by making the right thing to do easier to do. It is important that health IT maximizes patient safety while minimizing harm. On its turn, the field of patient engagement tools that rely on health IT is rapidly developing and offers many potential benefits to patient care. However, the unintended consequences these tools may have, such as threats to patient safety, have not been adequately studied. The increasing use of health IT by consumers, patients, and families creates an urgent need for the development and support of a research agenda to inform future public policy about the design, implementation, and use of such tools.[19]

The question is how to benefit from digital and improve patient safety.


  1. It is crucial to develop a robust regulatory process that ensures safe use of digital health and medical technology
  2. According to the Jeddah Declaration on Patient Safety (Statement No. 9)[5] Consider Medical Devices and Human interface as crucial factor for Patient Safety and thus encourage health-care systems to adopt human factors engineering strategies to introduce resilience and minimize medical devices related adverse events
  3. To develop a standardized taxonomy for patient safety (national, regional, and/or citywide) and consider the development of an International Classification of Adverse Events in alignment with ICD.

  Implementation Science and Patient Safety Research Top

In health-care improvement, the stakes are high, and resources are scarce, making decisions based on reliable evidence crucial.[20]

However, evidence and knowledge generated from research are not always incorporated into policies and practices on patient safety. Translational research in different contexts and settings will effectively address specific needs and respond to country-specific situations, while special attention to the needs of vulnerable population groups.[4]

While there is no doubt about the need for more evidence, there is enough evidence of efficacy to start now. Since the past 20 years, we have come a long way with regard to filling the evidence gap existing in the field of patient safety and therefore modern system sciences and several decades of distributed experience in quality improvement offer a firm foundation for starting on the road to implement evidence-based strategies that ensure a safer provision of care.[1]

On March 2013, well-evidenced recommendations were published. These interventions had proven to be highly effective in preventing patients from harm: presurgery checklists and anesthesia checklists; bundles to prevent central-line infections that include checklists; interventions to reduce urinary catheter use, such as catheter reminders and nurse initiated removal protocols; bundles to prevent ventilator-associated pneumonia, such as head-of-bed elevation and sedation vacations; mandated hand hygiene practices; a do-not-use list for hazardous abbreviations; interventions to reduce pressure ulcers; precautions to prevent hospital-acquired infections; real-time ultrasonography use while placing central lines; and interventions to improve prophylaxis for VTEs.

Despite the fact that evidence keeps accumulating, implementation of best evidence remains inconsistent.[21]

So what is/are the main challenge(s) for patient safety measures implementation?

Dixon-Woods et al.[22] identified ten key reasons: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and “projectness; organizational cultures, capacities, and contexts; tribalism and lack of staff engagement; leadership; incentivizing participation and 'hard edges'; securing sustainability; and risk of unintended consequences.”

The gap between research and implementation is of 17 years.[23] Implementation science is the drive to close this gap.

Implementation science is the scientific study of methods that promote the uptake of research findings into routine health care in clinical, organizational, or policy contexts. Investing in implementation research should be paramount of national patient safety research agendas. A linked problem is how to enhance quality of care and patient safety based on evidence when care settings are complex adaptive systems.[24]

To answer this question, it is imperative to understand which common implementation factors are associated with improving the quality and safety of care for patients. Once these factors are identified, the equation for implementation success is completed.

Proctor et al. (2010) identified eight implementation factors that must be taken into consideration while aiming for successful implementation of patient safety-related strategies: acceptability, adoption, appropriateness, feasibility, fidelity, implementation costs, coverage, and sustainability. These factors need to be considered while measuring the effectiveness of implementation.

Patient safety research should shift from clinical effectiveness to implementation effectiveness studies in which the implementability of interventions, as an outcome, should be considered.

Twenty years ago, it was evident that the lack of knowledge around patient safety interventions aimed at reducing patient harm. Inputs were taken from other industries, such as aviation, oil and gas, and nuclear, and therefore, novel interventions were developed, and effectiveness evaluated. Twenty years later, health-care decision-makers and policymakers are now well equipped with solid evidence that support safety in provision of care and yet implementation gap is a reality. To this point, funding programs should direct their attention to implementation studies of well-evidenced patient safety interventions.
Table 1: Example of how high-reliability organization principles can apply to health-care industry[7]

Click here to view

Moving forward, to transform patient safety over the next 20 years, it is imperative that health-care systems recognize patient safety as a public health issue and thus focus on implementation strategies that reduces the so-called “2nd translational gap,” successfully scales patient safety programs and by this means maximize the added value of the expansive evidence base on patient safety.


  1. Adapt known best practices in patient safety to fit the local context
  2. According to the Jeddah Declaration on Patient Safety (Statement No. 11)[5] is crucial to reduce the 2nd translational gap by supporting implementation and sustainable scale-up of patient safety interventions of known efficacy/effectiveness at national and global level
  3. Funding programs should direct their attention to implementation studies of well-evidenced patient safety interventions.

  The Jeddah Declaration on Patient Safety Top

The Jeddah Declaration on Patient Safety is founded on the principles that guided the 4th Global Ministerial Patient Safety Summit 2019, Jeddah, Kingdom of Saudi Arabia, which, in turn, sets recommendations for international standards, guidelines, and actions that aim to address patient safety issues of global significance, with a strong emphasis on LMICs.

The Jeddah Declaration on Patient Safety is a call for action on many fronts, and for many actors, at all levels of health-care provision and delivery – from frontline, to organizational and policy arenas.

The declaration is set on the underlying spirit that it is imperative to reflect on the effectiveness of the current practices in light of the now mature patient safety evidence base of 20 years; and to collectively move forward with a vision to sustainable and scalable implementation of patient safety solutions known to improve care delivery systems, patient outcomes, and safety culture. It is an involving document, where its eleven statements of actionable items reflect commitment for any country that objectively aims to develop health systems that are free of harm.

The declaration signals a strong collective and global commitment to shape truly safer systems for generations to come.

The Jeddah Declaration on Patient Safety is available in both Arabic and English language through the following link: https://spsc.gov.sa/English/Summit/Pages/JeddahDeclaration.aspx.

  Conclusion Top

For many years, patient harm was accepted as unavoidable while receiving health care. However, to keep patients safe is a fundamental part of care. It is imperative to reflect on the effectiveness of the current practices and collectively move forward, wiser, and committed to shape truly safer systems for generations to come.

Twenty years after the watershed report “To Err is Human,” it is time that we get past declarations of commitment and collectively move forward with a vision, that is actionable, to sustainable and scalable implementation of patient safety solutions, where “ first do no harm” is the true north for real safe health-care systems.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Slawomirski L, Auraaen A, Klazinga N. The Economics of Patient Safety: Strengthening a Value-Based Approach to Reducing Patient Harm at National Level. Paris: OECD; 2017.  Back to cited text no. 3
World Health Organization. Global Action on Patient Safety. Executive Board: 144th Session. EB144/29. World Health Organization; 12 December, 2018.  Back to cited text no. 4
Jeddah Declaration on Patient Safety. Fourth Global Ministerial Summit on Patient Safety, Jeddah, Kingdom of Saudi Arabia: Jeddah Declaration on Patient Safety; 03 March, 2019. Available from: https://www.spsc.gov.sa/English/Summit/Documents/JeddahDeclaration-En.pdf. [Last accessed on 2019 Mar 13].  Back to cited text no. 5
World Health Organization. 10 Facts on Patient Safety. World Health Organization; March, 2018. Available from: https://www.who.int/features/factfiles/patient_safety/en/. [Last accessed on 2019 Mar 13].  Back to cited text no. 6
Kadrie M. High reliability organization in the healthcare industry: A model of performance excellence and innovation. SOJ Nurs Health Care 2017;3:1-9.  Back to cited text no. 7
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Federal Aviation Administration; 2016.  Back to cited text no. 9
Griffith JR. Understanding high-reliability organizations: Are baldrige recipients models? J Healthc Manag 2015;60:44-61.  Back to cited text no. 10
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