WHO Implication of the covid-19 pandemic for Patient Safety – a rapid review (2) What is an 'adverse event'?

2 September, 2022

Dear Richard,

Thank you for your notes on the WHO webinar 'Implicatiion of the covid-19 pandemic for Patient Safety – a rapid review'.


The publication states that 'Prior to the COVID-19 pandemic, an estimated 134 million adverse events occurred annually due to unsafe care in hospitals in low and middle-income countries alone, and were estimated to contribute to 2.6 million deaths', but it's not clear how this is calculated and how the term 'adverse event' is defined.

The publication refers to the following reference National Academies of Sciences Engineering and Medicine. Crossing the Global Quality Chasm: Improving Health Care Worldwide. Washington (DC): National Academies Press2018 (https://www.nap.edu/catalog/25152/crossingthe-

global-quality-chasm-improving-health-care-worldwide, accessed 23 May 2022) and the figures appear to be based on just six categories of adverse event:

1. Adverse drug events

2. Falls

3. Ventilator-associated pneumonia

4.Decubitus ulcers

5. Catheter-associated urinary tract infections

6. Venous thromboembolisms

These six categories surely don't cover all 'adverse events'. For example, a misdiagnosis, with consequent inappropriate management decisions, would be a major cause of adverse events, but do not seem to be included?

This categorisation also does not focus on what is the most important factor: quality of care. An alternative approach to describing adverse events in relation to quality of care might look different to the above. For example:

1. Avoidable death

2. Avoidable morbidity

3. Incorrect diagnosis

4. Incorrect treatment


I would be interested to learn more about how we define and categorise adverse events.

Best wishes, Neil

Neil Pakenham-Walsh, Global Coordinator HIFA, www.hifa.org neil@hifa.org

Global Healthcare Information Network: Working in official relations with WHO