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A Global Quest for Reducing Harm in Patient Care

February 2019 Vol 12, No 1 - Editorial
David B. Nash, MD, MBA
Editor-in-Chief, American Health & Drug Benefits Founding Dean, Jefferson College of Population Health, Philadelphia, PA
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Improving the quality and safety of care in the inpatient and ambulatory settings is, indeed, a global quest. As part of this journey, I had the privilege of traveling to Kuala Lumpur, Malaysia, for the 35th Annual Meeting of the International Society for Quality in Health Care, known as ISQua. I would like to report on aspects of this meeting, especially those related to the safety of medication administration and the use of pharmaceuticals in general.

To prepare for the nearly 2 days of travel necessary to reach Kuala Lumpur from Philadelphia, I continued my self-education about quality and safety from a global context. Careful readers of American Health & Drug Benefits know that we have focused a good deal of our editorial energy on the need to reduce harm as it relates to medication administration. Admittedly, this remains an important problem domestically, and I learned just what a global quest this really has become.

Specifically, I was very impressed by a recent report from the Organisation for Economic Co-operation and Development (OECD), “The Economics of Patient Safety in Primary and Ambulatory Care: Flying Blind.”1 I will summarize aspects of this important report as a context for the work that I was involved with at the ISQua meeting in Malaysia.

According to the OECD, there are certain key messages regarding reducing harm from care delivered in the primary and ambulatory care settings. These key messages include the reality that “safety lapses in primary and ambulatory care are common; many of them can be avoided. Estimates show that as many as 20%-25% of the general population experience harm in this setting in developed and developing countries respectively. Some estimates say that as many as 4 out of 10 patients are harmed in the primary/ambulatory setting. Most harmful are errors related to diagnosis and prescription and the use of medicines. Up to 80% of harm in primary and ambulatory settings can be avoided.”1

I found it quite disturbing that ambulatory care, especially as it relates to medication administration, remains a dangerous interaction from a global perspective.

Another take-home message from the OECD report suggested that “the financial and economic costs of safety lapses are high. Available evidence estimates the direct costs of harm—the additional tests, treatments and health care—in the primary and ambulatory setting to be around 2.5% of total health expenditure, although this likely underestimates the true extent. Harm in primary and ambulatory care often results in hospitalizations. Each year these may account [for] over 6% of hospital bed days and more than 7 million admissions in OECD countries.”1

From every perspective, including the moral perspective to reduce harm and the economic perspective to reduce waste, ambulatory errors remain an important challenge.

The final, and most important, take-home message from the report noted that “regardless of a country’s stage of development, none of the elements described,…are possible without a buoyant, positive safety culture focused on collective improvement and teamwork. This can only be achieved with leadership at all levels of the health system. Political leadership is essential.”1

I have always been a strong proponent of the direct connection between leadership and the reduction of harm in all healthcare settings.

With this OECD report as context, I participated in 2 important activities as part of the global quest to reduce harm and improve the quality and safety of medical care. Along with my colleague, Billy Oglesby, PhD, MSPH, FACHE, Associate Dean for Academic and Student Affairs at our College of Population Health, we submitted a competitive presentation proposal, which was accepted by the steering committee for the ISQua meeting. Our presentation was titled “Developing an Accreditation Framework for Graduate Programs in Healthcare Quality and Patient Safety.”

This simultaneous lunchtime session on the third day of the 4-day meeting was an opportunity for Dr Oglesby and me to summarize our work nationally. Specifically, we are in the process of bringing together the 8 extant degree-granting programs in quality and safety in North America. These so-called founding programs have committed among themselves to a rigorous self-evaluation that will eventually lead to the certification and accreditation of the curriculum. With our partners at the Commission on Accreditation of Healthcare Management Education (CAHME), which is headquartered in Rockville, MD, these 8 leading universities exemplify what it means to be a true leader.

By working together and casting aside competitive tendencies, these 8 programs will help to define graduate-level education in quality and safety worldwide. Dr Oglesby described the various components of academic accreditation, including accreditation standards, such as graduation and employment rates, faculty qualifications, and curricular standards, as well as minimum credit hours and in-person versus online delivery of course content. He also discussed the necessary professional competencies that already exist, including work from the National Academy of Medicine, the World Health Organization, and the National Association for Healthcare Quality. We believe that by 2020, the partnership with CAHME will result in certification and accreditation standards worldwide.

At the close of the conference, I had an opportunity to work with some ISQua leaders to produce online video content, which becomes part of the library of content offered by ISQua. My video program was titled “Exploring Quality and Safety in the USA Ambulatory Arena.”

I divided my 40-minute video program into 4 parts, including (1) the challenges facing the US healthcare system, with a special focus on current waste in the system, poor outcomes, and comparative data between the United States and other nations; (2) the transformation of the US healthcare system, with a special emphasis on our journey from volume to value, especially as it relates to ambulatory care; and (3) action items that are relevant to improving ambulatory quality and safety, such as reducing adverse drug events and improving care coordination. In the fourth part, I made specific informed predictions about the future as it related to patient engagement and the rise of consumerism and its link to reducing harm. This video content will be available to ISQua members in early 2019.

Reducing harm and improving outcomes while reducing waste is indeed a global quest. ISQua is to be congratulated for its 3 decades' long history of bringing leaders, scholars, practitioners, and others together on a global basis to tackle this important challenge. I am proud that our college is playing a small, but vital, role in this quest. Next year, ISQua plans to meet in Cape Town, South Africa, to continue the quest for healthcare quality.

As always, you can reach me via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..

Dr Nash is Editor-in-Chief, American Health & Drug Benefits, and Founding Dean, Jefferson College of Population Health, Philadelphia, PA.


  1. Organisation for Economic Co-operation and Development. The Economics of Patient Safety in Primary and Ambulatory Care: Flying Blind. 2018. Accessed October 1, 2018.
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Last modified: August 30, 2021