Dear HIFA colleagues,
I'd like to introduce Question 3. What can be done to better understand and improve health systems for safer care for people living with NCDs?
Unsafe care for people living with noncommunicable diseases (NCDs) remains a major and often preventable cause of harm worldwide. We now have a good understanding of how harm occurs. However many health systems still struggle to provide safe, coordinated, and reliable care for conditions such as diabetes, hypertension, cardiovascular disease, chronic respiratory disease, and cancer. These challenges affect millions of people every day, especially those in low-resource settings.
When patients come to harm because of failures in their healthcare it is still all too common to blame individual staff. This is seldom warranted and is a seriously misguided approach to safety. We have learned over many years that the real causes lie in weaknesses in healthcare systems. Lack of resources plays an important part of course. However, even in poor systems, many vulnerabilities in systems can be identified which are not resource related and are putting patients at risk. There are opportunities everywhere to improve safety often with relatively simple interventions.
Unsafe NCD care is rarely due to a single failure and isolated human errors are relatively uncommon. Unsafe NCD care emerges from systemic gaps in primary care, information access, coordination, training, supply chains, equity, and governance. Understanding these gaps is the first step toward designing safer, more resilient systems.
Gaps include (among others) weak primary health systems resulting in misdiagnosis, mismanagement, communication failures among healthcare providers, limited access to reliable information, stockouts of medicines, insufficient training, excessive workload, lack of digital health support, lack of national or facility-level policies for patient safety.
We invite HIFA members to share their experience, insights, and examples from practice, research, policy, or community engagement. In particular, we welcome reflections on:
1. Any examples of unsafe care in your personal experience, whether as a patient or healthcare provider. What happened, what were the causes, how was it dealt with (blame? improved processes?)
2. Key health system gaps that contribute to unsafe care
3. Successful approaches that have improved safety or continuity of care
Your contributions will help us build a clearer picture of what works, what doesn’t, and what is needed to ensure safer care for people living with NCDs everywhere.
We look forward to your thoughts and experiences.
With best wishes
Charles Vincent
HIFA profile: Charles Vincent trained as a clinical psychologist and worked in the British NHS for several years. Since 1985 he has focused on conducting research on the causes of harm to patients, the consequences for patients and staff, and methods of improving the safety of healthcare. charles.vincent AT psy.ox.ac.uk
[*note from HIFA moderator (NPW): See overview and questions here: www.hifa.org/patientsafety ; to contriibute to the discussion, send email to hifa@hifaforums.org ]