Dear HIFA colleagues, We have had 22 messages exchanged so far and below is a brief summary. You can see all the messages in full on our website: www.hifa.org/read
You are encouraged to pass this on to your contacts and invite them to join us for the rest of the discussion.
Most important, please do share *your* experience of unsafe care, whether personal or professional. I shared my story of a missed diagnosis of epiglottitis with the hope that you might share yours. I am convinced that we have a huge amount to learn from this exchange. More so than, for example, reading an academic paper or a report.
SUMMARY
The discussion brings together clinicians, researchers, WHO staff, and community health practitioners to explore unsafe care for people living with noncommunicable diseases (NCDs). Contributors emphasise that unsafe care is widespread, often preventable, and deeply rooted in systemic weaknesses rather than individual failings.
Several messages introduce participants and set the context for the Spotlight week, highlighting WHO’s 2026 World Patient Safety Day theme (“Safe care for life!”) and the five global goals for safer NCD care. Contributors stress that people with NCDs are particularly vulnerable due to long-term treatment needs, polypharmacy, frequent interactions with health systems, and fragmented care pathways.
A major theme is the central role of reliable healthcare information. Multiple contributors argue that lack of access to up-to-date, evidence-based information — both for patients and health workers — is a critical and under-recognised cause of unsafe care. Messages note that WHO’s Global Patient Safety Action Plan 2021–2030 insufficiently acknowledges this issue.
The discussion includes powerful personal testimony. One contributor recounts a missed diagnosis of epiglottitis in 1986 that led to severe harm, illustrating how exhausted staff, inadequate staffing, delayed transfers, and lack of system awareness contributed. Charles Vincent expands on this case using James Reason’s human factors theory, emphasising that clinicians are often “set up to fail” by system defects.
Contributors from West Africa and the Dominican Republic describe unsafe care in low-resource settings, where weak infrastructure, medicine stock-outs, poor continuity, limited diagnostics, and financial barriers heighten risks. A vivid example from rural Dominican Republic shows how missed follow-up and fragmented information—rather than dramatic clinical errors—drive harm for patients with hypertension and diabetes.
Across messages, unsafe care is framed as a whole-system problem: failures in primary care, referral pathways, continuity, communication, training, supply chains, and governance. Several contributors call for stronger surveillance, incident reporting, digital health records, patient education, and community engagement.
The discussion closes with calls for shared learning, better integration of patient safety concepts in low-resource settings, and recognition that poor-quality care leading to death is, by definition, unsafe care.
Six verbatim, though-provoking points:
“Poor quality care is unsafe care.”
“Clinical staff are often ‘set up to fail’ by the systems they work in.”
“Unsafe NCD care is rarely due to a single failure.”
“Reliable information sits at the center of this.”
“Blame and recrimination are still far too common.”
With thanks and best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org