The neglected crisis of patient safety

Imagine Aliya, a young woman poised on the brink of a bright future as a writer, suddenly confronted by a strange tingling and weakness in her fingers. On a Saturday night, she found herself in the emergency room of a major hospital, unexpectedly faced with her academic dreams hanging in the balance. As we mark World Patient Safety Day on 17^th September, Aliya's story serves as a stark reminder of the critical importance of safeguarding patients in every healthcare setting.

An urgent MRI scan revealed a brain mass. With the specialist doctor already gone for the day to his private clinic, Aliya was admitted to the intensive care unit (ICU) overnight, to be seen by him in the morning. A recently graduated duty doctor , along with two night-shift technicians, tended to her and others in the 20-bed unit. Despite her family’s raising their concerns over her deteriorating condition, they were told that the senior specialist doctor had been informed and would attend to her in the morning. Tragically, by the time the doctor arrived, Aliya had lost the use of both her legs and slipped into a coma from increasing pressure in her brain from the mass. She was later declared brain-dead.

This tragedy highlights how delays in care, conflicting priorities, absence of streamlined healthcare protocols, and inadequate staffing can contribute to a lack of timely intervention, leading to preventable harm and immeasurable suffering. Sadly, Aliya is only a small footnote in a book filled with countless such events and stories.

The World Health Organization (WHO) reports that a staggering one in ten patients is harmed during healthcare delivery worldwide, resulting in over three million deaths each year. In low-to-middle-income countries (LMICs), this situation is more dire, with four in 100 individuals succumbing to unsafe care. As the global population grows - 70% of which is expected to occur in LMICs like ours - the burden of disease and adverse events due to unsafe care disproportionately affects these vulnerable communities

In Pakistan, patient safety is a concept that remains largely unfamiliar and often ignored. Challenges such as poor infrastructure and limited resources are frequently cited as the reasons behind unsafe care, alongside the ubiquitous “Allah ki marzi (God’s will)”. However, research shows that most preventable errors in healthcare stem from poor communication, lack of teamwork, and diagnostic errors including delayed treatment. These issues are indeed pervasive, but well within our power to address.

A systems-based conceptual approach to patient safety would require three crucial components. First, it is essential to create local evidence on patient safety and healthcare quality by conducting high-quality research to understand the problems and develop relevant solutions. Second, the culture within our healthcare system must change. This is a difficult task, but starting by including dedicated education on patient safety science for medical, nursing, and allied health professionals as early as possible is a first step. Third, we need to open the black box by raising awareness publicly about the issue and engaging all stakeholders, including patients, while fostering collaborations with relevant national and international leaders like the WHO.

Many transformative and lasting initiatives in human history have begun in academic institutes. Recognizing this, the Aga Khan University, already a leader in clinical quality, established a dedicated academic Centre for Patient Safety, supported by donor seed funding. This Center aims to improve patient safety in Pakistan and similar settings through research, education, and advocacy. Its early achievements include the publication of some of the first local studies on patient safety in international journals, the development of a the first dedicated curriculum on patient safety for the MBBS and BSN degrees, and the incorporation of academic input into national policies.

Improving patient safety in a country like Pakistan may seem daunting at first glance but the fundamental causes are addressable. Lasting change will require a multi-pronged approach involving academia, policymakers, healthcare professionals, and patients alike. This World Patient Safety Day, let us commit to build a healthcare system where patient safety is paramount, and every individual can actualize their right to safe, high-quality care.