Safer Primary Care

A Global Challenge

SUMMARY OF INAUGURAL MEETING

The Safer Primary Care Expert Working Group

WORLD HEALTH ORGANIZATION, GENEVA
27TH - 28TH FEBRUARY 2012

WHO/IER/PSP/2012.16
© World Health Organization 2012. All rights reserved.

WHO/IER/PSP/2012.16

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2 | Summary of Inaugural Meeting of Safer Primary Care Expert Working Group

Executive Summary
Since unsafe care was recognized as a public health promoting safer primary care with a special focus
problem, numerous efforts have been made to on low- and middle-income countries. This is a
understand its nature and key first step on the road towards developing
magnitude and to devise appropriate solutions aiming to improve the safety and
solutions. Most of this activity has focused on quality of primary care. The inaugural meeting
what happens to patients in hospital settings. of the Safer Primary Care Expert Working Group
But understanding the magnitude and took place at WHO Headquarters in Geneva,
nature of harm to patients outside the hospital, Switzerland from 27-28 February 2012.
especially in primary care, is of the utmost Participants included
importance given that the majority of doctor-patient representatives from Australia, Austria,
interactions take place in these settings. Bahrain, Canada, Denmark, France, Ghana,
Furthermore, accessible and safe primary Kuwait, the Netherlands, New Zealand,
care is essential to ensure universal coverage, Oman, Saudi Arabia, South Africa, Spain,
a priority goal of the World Health Switzerland, Tunisia, the United Kingdom
Organization (WHO) and Member States. (England and Scotland, UK), and the United
Very little is known about the possible risks to States of America (USA). The meeting was
patients that are frequently present in the primary opened by senior representatives of WHO,
and ambulatory care, as well as on the possible namely Dr Marie-Paule Kieny, Assistant-
impact of these risks on the health of patients. Director General and Dr Najeeb Al-Shorbaji,
It has been identified however, that a Associate Interim Director (PSP). Sir Liam
significant proportion of safety incidents captured Donaldson, WHO Director General’s Envoy for
in hospitals had originated in the earlier levels Patient Safety also gave a welcome address.
of care. Therefore, advancing the understanding The Safer Primary Care Expert Working
and knowledge about the risks to patients in Group considered, discussed and debated the
primary care, the magnitude and nature of the available evidence on the burden of harm
preventable harm due to unsafe resulting from errors – most of which originated
practices in these settings, and on the safe from high-income settings – and the global
mechanisms to protect patients, is essential in limited understanding of how to intervene to
order to secure access to safe and quality care. improve the safety of care in primary care
Particularly, this is very relevant for settings. The importance of focusing on
developing countries, where a high this hitherto largely neglected aspect of health
proportion of health care takes place in systems was underscored, particularly in the
primary care settings, often with important light of recent
limitations in infrastructure, as well as in pronouncements from WHO and others on the
procedures and standards for safe practices. crucial and increasing importance of high quality
The WHO Patient Safety Programme (PSP) intends primary care.
to reflect and prioritise the key knowledge Also emphasized, particularly, but not
gaps and challenges that exclusively in the context of low- and middle-
surround the safety of primary care. In income settings, was the considerable
collaboration with internationally renowned experts burden of preventable harm through poor
in the fields of primary care, research, and patient access to care and the need therefore to
safety, WHO PSP organized a programme of work consider the impact of such poor access on
aimed at producing a errors of omission and in avoidable harm and loss
global agenda for research and action in of health gain. Given the pressing need for
improving the safety of all types of care,
 Safer Primary Care: A Global Challenge | 3

the Group was of the opinion that greater This foundation will facilitate the opportunity for
understanding of the effectiveness of quality comparing and contrasting findings from different
improvement initiatives should be as well parts of the world in the near future. During the
considered in order to attempt to bridging the course of the meeting, the Safer Primary
gap between describing the current state of safety Care Expert Working Group
in primary care and taking active steps to make
participated in a three-round Delphi exercise
care safer.
to achieve consensus on the primary care
It was however recognized that more contexts and aspects of care provision that need
parsimonious step-wise approaches to priority attention both globally and by income
developing evidence, beginning with setting. Breakout groups discussed how to
epidemiological investigations and then translate the findings from this prioritization
moving to randomized controlled trials are also exercise into a limited number of focused
important in order to generate initiatives that can be taken forward with the
potentially transferable lessons. This support of funding partners.
realization, together with the recognition of the
Overall, considerable progress was achieved in
need to obtain a rich, multi-faceted
sharing experiences and insights from different
understanding of the frequency of errors and
parts of the world and developing a shared
associated harm, led the Expert Working Group
frame of reference to work
to emphasize the need for
collectively to improve the quality and safety of
underpinning conceptual and methodological work
primary care provision.
in order to help improve the quality of research and
quality improvement initiatives.

The major outcomes of the meeting were:

1. Recognition of the importance of unsafe primary care.

2. Willingness to work as a network around a common agenda, and

share instruments, tools, data and learning.
3. Support aimed at integrating baseline measurement with quality
improvement in low- and middle-income settings.
4. Identification of priority areas and key knowledge gaps.

5. Recognition of the need for increased knowledge together with

practical proposals to bridge major knowledge gaps.
6. Suggestions for a roadmap for action

This document provides a summary of the intellectual commitment invested by

evidence considered and generated, a members of the WHO Safer Primary Care
synopsis of the discussions and provides details Expert Working Group is now built upon as we
of essential next steps in ensuring that the try to realize the truth in that timeless maxim,
considerable time, effort and first do no harm.

4 | Summary of Inaugural Meeting of Safer Primary Care Expert Working Group

Background
The 1978 Declaration of Alma-Ata heralded a have made great progress in managing the
paradigm shift in healthcare. This argued that the
1
challenges of improving safety and reducing
key tenants of a modern healthcare system should harmful events. These industries have all
include a greater focus on equitable accepted that errors are inevitable and
healthcare, a patient-centered approach, provide opportunities to learn and improve from
management of disease in the community and them, have built systems that reliably deliver
preventive medicine. The move towards primary what is required, proactively seek to identify
care-based models of healthcare has however until errors and take steps to mitigate the risk of harm
recently been patchy with considerable progress resulting from errors that still occur. They are
in some parts of the world, but a persistence increasingly drawing on an understanding of
of specialist-based provision, particularly in low- and human factors to make the “right thing the easiest
middle-income country settings. There thing to do”, created teams of employees trained in
is however now growing international technical and non-technical skills and developed
realization that because of the increasing formal models of communication. Indeed,
demands on health systems, more cost- hospitals that have adopted such approaches
efficient models of care need to be have seen significant improvements in clinical
developed and invariably there is now an active outcomes. There is however a paucity of such
move globally towards developing community- initiatives being taken up in primary care, in
based patient-centered health systems. 2
part due to the heterogeneity of the settings
Furthermore, several challenges of social which range from the traditional healer to the
mobility have put a strain on the provision multi-partner family practice. But also, another
of primary care services – cause is the lack of a robust underpinning evidence
globalization and ageing populations posing unique base on the frequency of errors,
challenges. on the particular high risk contexts, and an
appreciation of the causal pathways through
Over the last two decades, there has been a growing
which these errors arise and translate
realization that healthcare provision may
into harm. As a consequence little is
inadvertently result in harm to patients. Whilst this
known about where and how to effectively
was considered in the classical polemics by the
intervene to improve the safety of primary care
likes of Ivan Illich and Peter Skrabanek, this field of
3 4

provision.
enquiry really took a step forward with the
studies by Leape, Berwick, and the US Institute of
5 6
The recognition of patient safety as a public
Medicine’s To Err is Human and the UK’s
7
health concern was noted in resolution 55.18 of
Organisation with a Memory reports. These
8
the World Health Assembly (WHA). This led to
15

landmark investigations were however centered the creation of the World Alliance for Patient
on hospital-based specialist care Safety almost a decade ago, which is now known as
provision. Secondary care the Patient Safety Programme (PSP) of WHO.
practitioners have, building on this evidence, Several key pieces of work have been undertaken
travelled further than their primary care colleagues under the auspices of WHO, which focus on
16

in the patient safety journey; they have been able to understanding the risks from healthcare
estimate the prevalence of harm due to all and engineering appropriate solutions to
episodes of secondary care ranging from 3.2 to reduce the burden of harm due to unsafe
11 12 13 14
16.6% .9 10
They have also attempted to care. Particularly noteworthy and successful
adopt initiatives include the global campaigns: Clean
practices from other high-risk industries such as Care is Safer Care and Safe Surgery Saves Lives.
17 18

aviation, oil and nuclear power, which

 Safer Primary Care: A Global Challenge | 5

Building on the success of these and other related terms of conceptual frameworks,
initiatives, the Patient Safety typologies/taxonomies, epidemiology, risk
Programme of WHO has turned its attention as well factors or interventions all therefore
on primary care, where the majority of patient- potentially need to be developed in their own
clinician interactions now take place and where right in relation to primary care; it is
most healthcare is now delivered. Primary furthermore important, as noted above, that this
care poses unique challenges. evidence base reflects the variations in primary
It is, for example, very care provision in different parts of the world.
heterogeneous in its manifestations, involves
In attempting to begin deliberations on the issues
management of patients with a wide variety of
raised above, WHO commissioned a systematic
undifferentiated complaints and is in many parts of
review of the international
the world still poorly regulated and regarded. The
literature and convened the Safer Primary Care
relationships that patients have with their
Expert Working Group, comprising of leading
primary care practitioner is furthermore
world specialists with an interest in improving
different from other care settings
patient safety in primary care, in order to
in that it is, particularly in developed country
identify major knowledge gaps about patient
contexts, often more personal and longer-term
safety and avoidable patient harm in primary
than that provided through secondary or tertiary
care. The aim was to
care.
collectively make progress on achieving a step-
Simplistic attempts at transferring lessons from change in improving the safety of primary
specialist care settings to primary care is therefore care internationally.
not without problems. The underpinning
evidence-base, whether in

Aims of the inaugural meeting

Members of the Safer Primary Care Expert - Develop a working appreciation of
Working Group met for two days on the 27th primary care contexts internationally.
and 28th February 2012 at WHO - Assess and prioritize the key knowledge
Headquarters in Geneva to share their gaps about patient safety and
experiences and discuss ways of enhancing avoidable patient harm in primary care.
understanding of and improving the safety of - Understand the frequency,
primary care internationally. Experts came nature,
from a variety of backgrounds including burden and preventability of patient
patient safety, primary care, health policy safety incidents in primary care settings.
and academia (Appendix 1). - Appreciate the challenges related to
understanding patient safety issues in
The key aims for this inaugural meeting were primary care in low-, middle-, and high-
to: income settings.
- Create an unrivalled opportunity for - Suggest directions for further action
sharing of experiences and networking leading to bridging existing knowledge
with colleagues from across the world. gaps and delivering safer primary care.
The agenda of the inaugural meeting can be
found in Appendix 2.

6 | Summary of Inaugural Meeting of Safer Primary Care Expert Working Group

Participants to the meeting
Following the invitation of WHO to a range of
Though participants represented national
international experts in primary care, patient
and international constituencies from almost
safety, research, or a combination of these
all WHO regions in the world, not all invited
skills, 39 specialists were able to attend the
specialists were able to respond to the WHO
consultation. Participants included
call due to limitations in resources. WHO is
representatives from Australia, Austria,
committed to involve a growing number of
Bahrain, Canada, Denmark, France, Ghana,
interested parties and experts in the next
Kuwait, the Netherlands, New Zealand,
steps of the process in order to expand and
Oman, Saudi Arabia, South Africa, Spain,
maximize participation in this important area
Switzerland, Tunisia, the United Kingdom,
of work.
and the United States of America.
See Appendix 1 for list of participants.

Main areas for discussion

The five main areas for discussion were to: (i) options to translate the findings from the
reflect on preliminary findings from a prioritization exercise into a limited number
systematic review of the literature; (ii) hear of detailed proposals across low-, middle-
about ongoing conceptual, methodological and high-income settings; and (v) have a final
and epidemiological work in different parts brainstorming session to help formulate next
of the world; (iii) undertake a formal steps. Key points arising from each of these
consensus building exercise to identify areas are discussed below.
priorities for future work; (iv) discuss about

Systematic review: the global burden of patient safety incidents

in primary care

As part of work aiming to understand the scope of harm in primary care and identify
and gaps for conducting research on patient potential gaps and priority areas.
safety, WHO commissioned in 2008 a review of the
literature focusing on primary care. This review Preliminary findings
noted the scarce attention given to patient safety  Our search revealed a total of 47,223
in this level of care and highlighted some of the references from which we screened
many prevalent gaps, including the need for 15,624 titles; from these, we selected 167
research in low and middle-income countries. This 19
primary studies and 9 systematic reviews.
follow- up work will update the earlier study seeking  Most studies (54.5%) have been
to: carried out in general/family practice
 Estimate the frequency of patient safety settings followed by community
incidents and disease burden associated with pharmacy and ambulatory care clinics.
primary care globally.  Low- and middle-income countries
 Describe approaches used to understand contribute a very small proportion to the
underlying causal factors and literature on patient safety in primary
preventability of these patient safety care (9/167, 5.4%). High- income
incidents. countries contribute almost 20 times as
 Inform future work on developing much to the understanding of harm
methods to measure the global burden caused by patient safety
 Safer Primary Care: A Global Challenge | 7

incidents in primary care (158/167, typologies of harm varied widely as well

94.6%). The multi-country studies did not across studies, highlighting the lack of a
involve any low-and middle- widely accepted taxonomy specific to
income countries (2/167, 1.2%). A global primary care. A full
representation of the research activity is description of the results of the
shown in Figure 1. literature review is covered in a
 We broadly identified four common separate publication.
methodological design categories for  In addition, certain contexts where
measurement of harm in primary care; these patient safety incidents were most
included systematic reviews (n=9), the prevalent became apparent; these
control arms of experimental include errors in the medication
studies (n=3), process, particularly in elderly patients with
epidemiological study designs (n=108) and multiple morbidities.
qualitative methods (n=56).  We estimated that, overall, mild to
 The most commonly studied areas of moderate harm associated with errors of
iatrogenic harm in primary care were commission was more common than
medication errors, followed by office- serious harm. Severe harm
administration errors and then seemed associated with prescribing and
communication errors. misdiagnosis/delayed diagnosis.
 There was a lack of standardized  Varying estimates of preventability of all
information on the frequency, burden of types of patient safety incidents for patients
harm and preventability of patient safety seeing a primary care
incidents in primary care. As a result, practitioner were also offered.
estimates of frequency varied widely across Preventability seemed associated with
studies. Furthermore, the definitions of process errors related to medications,
errors and the administration and communication.

Discussion on the review

The complete review of the literature was shared Despite recognizing the policy relevance of
to the Safer Primary Care Expert Working Group understanding the global burden of harm in
for comments subsequent to this inaugural primary care, the heterogeneity and broad scope
meeting. This review is an of the field also called for more in- depth and
attempt to offer a baseline on the key areas of specific analysis into particular areas of risk. For
iatrogenic harm due to errors in primary care and instance, patient harm may increase with the
was presented as a background document to the greater frequency and complexity of
expert consultation. consultations and/or
interventions. The same effect may be seen
The discussion that followed the
if a patient has increased physical, cognitive and
presentation of the review highlighted the
emotional vulnerability. As such it was
scarcity of data, particularly from developing and
deemed essential to understand the harm
transitional countries, as well as the lack of
occurring around specific interventions and high-
established consensus on the principles, and
risk patients and contexts.
concepts underlying unsafe primary care. Also gaps
were highlighted in valid and reliable Limitations of human and institutional
measures and measurement capacity to advance quality and patient
methods. Hence, there was great difficulty in safety practices as well as research, including the
establishing global estimates of patient safety limited opportunities for expanding
incidents and harm in primary care. These gaps appropriate training, the need for fostering the
were later identified as important areas to patient safety and improvement culture across
consider and meet in the path towards safer organizations, health care institutions and
primary care. clinicians, and the increasing difficulties

8 | Summary of Inaugural Meeting of Safer Primary Care Expert Working Group

in obtaining additional resources to secure resulting from errors of omission will be
improvements, were highlighted as well. especially useful, as will the better
understanding on the effectiveness of
New research, including an international study
interventions in patient safety and primary care
to measure harm in low-and middle- income
and/or quality improvement initiatives in the
countries using robust
same area.
epidemiological techniques; and a parallel piece
of work on the burden of harm

Figure 1: Global participation in patient safety research associated with primary care

The size of the dot ● represents the number of primary studies undertaken in these geographical locations

There are two multi-center studies not listed on the map: the first study included Australia, Canada,
Netherlands, New Zealand, the United Kingdom and the United States of America ; the second study
20

included Australia, Canada, England, the Netherlands, New Zealand, and the United States of America.21
 Safer Primary Care: A Global Challenge | 9

Presentations during sessions

The consultation hosted a series of primary care in various contexts and

presentations, including the results and socioeconomic settings. These were
summary of the methodological gaps in discussed by the LINNAEUS group (Aneez
patient safety and primary care identified Esmail), the Gulf countries (Tawfik Khoja),
earlier (Meredith Makeham) and an SafeCare Africa (Nicole Spieker), the Institute
overview of key findings from the systematic for Healthcare Improvement (IHI) in Ghana
review (Sukhmeet S. Panesar and Andrew (Nana Twum-Danso), the PAHO-AMRO
Carson-Stevens). But moreover, it focused on Adverse Events in Primary Care Latin
the global challenges faced by teams American group (Ludovic Reveiz) and
studying and trying to improve the safety of Scotland (Neil Houston).

Consensus building exercise: identifying priorities for safer

primary care: insights from an international working group

During the meeting, a priority setting important sources of patient safety

exercise was conducted following a modified Delphi incidents across all economic
methodology. The aim was to develop consensus settings.
about the most relevant patient safety issues and  Additional areas to focus on in low- and
the areas and contexts for improvement in primary middle-income settings included
care. The exercise involved 3 rounds of counterfeit drugs (100% and 82%
consultations. respectively) and errors in the
execution of clinical tasks (100% and 96%
Preliminary findings respectively), whilst country- specific
 Family practice and pharmacy were issues in high-income
considered as particular priority areas settings included higher-level
for advancing patient safety across all systems management (e.g. human
income categories (with 92-100% and resources, 88%) and technology-
88-96% agreement respectively). related factors (89%).
 Additional key primary care contexts that
Discussion
were identified as warranting particular
 This work is an attempt to inform
attention included
community midwifery (92% efforts to measure and address the
agreement) and community nursing (91% extent of inadvertent harm in
agreement) in low-income primary care settings with different levels
countries and care homes in high- of income, and reflect the opinions of
income countries (84% agreement). the meeting participants.
 Communication between healthcare  The exercises suggest that, in terms of
professionals and with patients (86- 100%), contexts, efforts should focus on family
teamwork within the practice and pharmacy
healthcare team (87-100%), settings across income categories;
laboratory and diagnostic imaging community midwifery and
investigations (85-96%), issues community nursing in low- and
relating to data management (87- 96%), middle-income countries; and care
transitions between different levels of homes in high-income countries.
care (87-96%), and chart/patient  Areas to be investigated across
record completeness (82-84%) were income settings should include
identified as the most communication between healthcare
professionals and with patients,
teamwork within the healthcare
10 | Summary of Inaugural Meeting of Safer Primary Care Expert Working Group
 team, laboratory and diagnostic be relevant in many contexts. These
imaging investigations, issues include injection safety and maternal care
relating to data management, which are recognised patient safety
transitions between different levels of problems of particular importance
care, and chart/patient record in developing countries, though these
completeness. were not highlighted here. It will be
 Counterfeit drugs and errors in the important to expand this exercise,
execution of clinical tasks are including broader assessments
important additional areas primarily in of the literature and expert opinion, in
low- and middle-income settings, whilst order to arrive at a global set of priority
high-income settings may area
wished to focus on higher-level
systems management as well as in
A draft paper was circulated to the Safer
technology-related factors.
Primary Care for All Expert Working Group
 Other important issues were not
following the meeting with an aim to submit it for
identified in this exercise, but may
publication.

Prioritizing issues and challenges to bridge knowledge gaps on

unsafe primary care: discussion groups based on economic
setting

Three lively discussions focusing on specific The middle-income group led by Aziz Sheikh
challenges to overcome the existing gaps across reiterated that primary care was an emerging
different settings (high-, middle- and low-income specialty and unless initiatives of safer
countries) also took place during the meeting. primary care were intertwined with quality
improvement, there would be limited
The high-income group led by David W Bates and
support from governments who would be
Anthony Avery highlighted some of the prevalent
cautious about funding studies of errors in
issues such as lost laboratory and radiology tests,
primary care as these might gain negative
medication errors, issues and adverse events
publicity. Nevertheless, innovative studies were
occurring at the transitions of care, diagnostic
proposed to study our understanding of safer
errors, communication (physician and
primary care in these settings; these included a
patient; between physicians); handovers of care;
prospective study looking at a number of high-
non-compliance and adherence problems; and
risk patients (e.g. the elderly and/or poly-morbid
computer systems. Various measurement tools
patients) and using a mixed-methods approach
were proposed which included fieldwork and
to determine the frequency, burden of
database analyses. Among the suggestions
harm and preventability of
proposed were to design and promote the use
errors; a study involving simulated patients
of clinical and safety practices in bundles, to
sent to primary care centers and community
develop tools for increased communication across
pharmacies to assess the inappropriate use of
professionals, as well as change management
antibiotics and medication errors and a multi-
and improvement packages associated to clinical
center study to assess patient safety incidents
safety practices. Team training and increased use
that occur during transitions of care from
of information technology (IT) in clinical care were
secondary to primary care settings and vice-versa,
also seen as essential enablers.
as well as the effectiveness of a quality and
safety improvement tool. Thus safety should be
considered an extension of quality of primary care.
 Safer Primary Care: A Global Challenge | 11

The low-income group led by Amardeep Thind The suggestions relied on building upon
noted that primary care needed to be viewed as existing experiences and resources already
continuum and should include any aspect of care deployed in these countries leading to new
outside the inpatient setting. Furthermore, they research proposals and patient safety or
suggested that common priorities for safer primary quality improvement tools. As such, the
care be identified and consequently, a suitable group made suggestions to build synergies
multi-center study be designed to quantify the across quality improvement projects, such as in
frequency of errors and burden of harm in primary the area of quality standards, data collection
care for these settings. systems, and trigger tools for example.

General discussion points

 Many participants had varying diagnostic, therapeutic, and adjunct

definitions of primary care and this is indeed secondary prevention and educational
an important consideration going forward. services for non-admitted patients that
We have opted for the definition suggested are community-based.
by WHO at the Declaration of Alma-Ata.  Participants at the meeting
considered that there is a need to
undertake further
‘‘Primary health care is essential health care based on underpinning of conceptual and
methodological work to include
practical, scientifically sound and socially acceptable the creation and/or refinement
methods and technology made universally accessible to of appropriate
taxonomies for adverse events,
individuals and families in the community through their full hazards and risks in primary care.
participation and at a cost that the community and The systematic review noted
country can afford to maintain at every stage of their significant progress from the
LINNAEUS group on this front.
development in the spirit of self- reliance and self- The conceptual
determination. It forms an integral part both of the discussion about the
boundaries of safety and
country's health system, of which it is the central function
quality may need to be looked at,
and main focus, and of the overall social and economic although it was realized that both
development of the community. It is the first level of concepts are part of the same
continuum.
contact of individuals, the family and community with the  It was also debated
national health system bringing health care as close as whether the focus should be on
possible to where people live and work, and constitutes the events of commission or
omission. Different schools of
first element of a continuing health care process.’ thought exist on this: errors of
commission have traditionally been
Definition of Primary Care Alma Ata, WHO (1978) studied, as they were the first group
to be highlighted in the landmark
 The scope of primary care as report, To Err is
discussed in this meeting includes the care Human. Consequently, medication errors
that is provided by the first point of contact have been studied extensively and
care, and also the provision of single- interventions to reduce these errors
or multi-disciplinary have been tested in several settings.
Errors of omission are those
 12 | Summary of Inaugural Meeting of Safer Primary Care Expert Working Group

errors that occur as a result of a step not including equipment, education, and staff
being taken or when an skill-mix and patient harm.
appropriate step is left out from a  Data infrastructure, data collection and
process. Both aspects need to be systems and mechanisms for review,
understood in order to facilitate a and reporting are other areas where
comprehensive approach to safe there are persistent and
primary care. important gaps, together with more
 Among the gaps that were recognized were methodological developments in terms
the need for measuring harm and of measurements, and
establishing a baseline on the appropriate metrics.
epidemiology, burden of harm and costs  The group recognized the need and
of unsafe primary care to the health advantages of mechanisms for sharing
system and to patients. The experiences, tools and lessons of those
realization of this gap was the basis of the involved in delivering safer primary
proposals for high quality studies on these care. This could be a first step
through a wide spectrum of sites, including to facilitate collaborative group working.
and prioritizing low- income countries  Increased advocacy through engaging policy
and transitional countries. makers and research
 Importantly, the group felt the need to commissioners is important, as is the
increase the understanding of the production of a document outlining the
relationship between safety culture and gaps and roadmap to safer primary
safety; as well as the relationships between care.
lack of infrastructure,

Conclusions
Despite improvements in patient safety increased advocacy aiming to raise
globally, little is known about the global policy attention and action.
contribution of primary care to avoidable patient 2. Willingness to work as a network around a
harm. Overall, there was a clear common agenda and of sharing
consensus about need to progress the area of instruments, tools, data, and learning.
patient safety in primary care 3. Identification of priority areas and major
internationally. This will require a concerted effort, knowledge gaps, and recognition of the need
where WHO can steer through its roles as a for bridging existing major
leading international health organization and knowledge gaps through concrete
global convener. The initiatives proposed must initiatives in countries across all socio-
also be sensitive to the different points that economic status.
various countries find themselves on the patient 4. Recognition of the need for integrating
safety journey, measurement with quality or patient
especially in developing and transitional safety improvement in low-income
countries. Both better understanding of the settings.
epidemiology of unsafe care, including the 5. Agreement on drafting a roadmap for
causality of adverse events and patient harm, and global action.
development of new solutions to improving 6. A series of publications covering the
safety will be required. points above were also suggested.
This 2-day meeting led to important The overall perception is that patient safety
outcomes that can be expressed as follows: in primary care is an important issue that
needs to be addressed in all parts of the
1. Recognition of the importance of unsafe world. Even with the limitations due to the
primary care, and therefore the need for
 Safer Primary Care: A Global Challenge | 13

scarcity of data, there is evidence that a measurement for improvement through

significant fraction of primary care visits result implementation of robust research,
in patient safety incidents and in patient harm. especially in low-income countries. Specific
There are serious gaps in data and knowledge from suggestions to strengthen the field include
most parts of the world, particularly from reinforcing the structure of primary care
developing and transitional countries. Efforts are include better clinical standards, improved
needed to understand the magnitude and nature training, inclusion of bundle of interventions,
of unsafe care problems in primary care as linking technical with structural incentives,
well as its epidemiology. A number of important adapting the interventions to the structure and
issues in patient safety in primary care were context of primary care, promoting patient
identified through the literature review. Patient safety culture and leadership for patient
safety issues in primary care should not be taken in safety, focusing on high-risk
isolation but in the context of the continuum of populations, and adopting mixed-method
care. We need to drive approaches for research purposes.

Suggestions for next steps

 Production of a “roadmap for action.” primary care was created by WHO to
This publication will highlight the current facilitate collaboration.
state of knowledge and identifies the
 Mobilize additional funding
main priority areas and gaps with
/resources and facilitate a
suggestions for further advancing patient
collaborative structure, including
safety in primary care. This WHO
interested agencies and institutions and
publication will serve mainly for increased
WHO by virtue of its convening role.
awareness and advocacy for action around
unsafe primary care and lay out directions  Recognition of the need to set up
and paths for research and progress. focused, specific working groups.
Experts further recognized the need for
 Recognition of the benefits to work
different working groups to be set up,
collaboratively. The Safer Primary Care
with some focusing on
Expert Working Group stressed the
conceptual and others on more
importance of facilitating
practical considerations
platforms for interaction and sharing of tools
and materials, and learning. Suggestions  There was further a clearly expressed need
were made to explore opportunities in this for a follow-up international meeting in
area, taking into account existing approximately a year’s time to assess
resources by participating progress and keep up the considerable
institutions and WHO. An online momentum generated by this
communication platform in support of a inaugural meeting of the Safer Primary
global network for safer Care Expert Working Group.

14 | Summary of Inaugural Meeting of Safer Primary Care Expert Working Group

Appendix 1 List of Participants at Inaugural Meeting

Safer Primary Care: A Global Challenge | 15

Appendix 1 List of Participants at Inaugural Meeting (Cont.)

16 | Summary of Inaugural Meeting of Safer Primary Care Expert Working Group

Appendix 2: Agenda of meeting

Safer Primary Care: A Global Challenge | 17

Appendix 2: Agenda of meeting (Cont)

18 | Summary of Inaugural Meeting of Safer Primary Care Expert Working Group

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Safer Primary Care: A Global Challenge | 19

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