World Patient Safety Day

Spread the Message

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A diagnosis identifies a patient’s health problem. To reach a diagnosis, patients and their health care teams must work together to navigate the complex and sometimes lengthy diagnostic process. It involves discussion with the patient, examination, testing and review of results before reaching the final diagnosis and treatment. Errors can occur at any stage and can have significant consequences. Delayed, incorrect or missed diagnosis can prolong illness and sometimes cause disability or even death.

The theme for this year’s World Patient Safety Day’s is focused on improving diagnosis for patient safety, using the slogan “Get it right, make it safe!”. On the day, patients and families, health workers, health care leaders, policy makers and civil society will emphasize the pivotal role of correct and timely diagnosis in improving patient safety.

Campaign objectives

Raise global awareness of errors in diagnosis contributing to patient harm and emphasize the pivotal role of correct, timely and safe diagnosis in improving patient safety.

Give prominence to diagnostic safety in patient safety policy and clinical practice at all levels of health care, aligned with the Global Patient Safety Action Plan 2021–2030.

Foster collaboration among policy-makers, health care leaders, health workers, patient organizations, and other stakeholders in advancing correct, timely and safe diagnosis.

Empower patients and families to actively engage with health workers and health care leaders to improve diagnostic processes.

Calls to action

These are the key actions you can take to help improve patient safety in diagnosis.

Patients, families and caregiversBe informed, involved, and proactive in your diagnosis
- Be actively engaged in the diagnostic process and with your health care team:
  - share accurate and comprehensive information about your symptoms and medical history;
  - make sure you understand the diagnostic process, your illness’ or symptoms expected progression, and next steps;
  - check your information is up-to-date, and keep track of your symptoms, medical visits, tests and treatments.
- Share your questions and concerns:
  - don’t be afraid to ask questions;
  - speak up, ask about alternative options or seek a second opinion if you need to;
  - share your experiences and contribute to making diagnosis safer for others.
Health workers providing clinical careMake diagnostic excellence integral to your daily practice
- Keep focussed on the person at the centre of the diagnosis:
  - listen to your patient, ask them about their concerns and tailor the interventions to their needs;
  - take a careful and thorough history and physical examination of your patient;
  - talk openly and empathetically with your patients, and encourage them to ask questions.
- Leverage available technology, tools, and tests to reach a diagnosis.
- Be a good team player and contribute to a safe and collaborative professional environment, where information is shared in a timely manner.
- Keep learning:
  - participate in regular training and seek feedback from your peers and patients;
  - contribute a culture of continuous improvement by sharing best practices, and information about errors and near misses with peers.
Health care facility leaders and managers.Implement safer systems to improve diagnosis, support your clinical teams and empower patients
- Empower the health workforce through policy, culture and practice:
  - ensure adequate staffing, resources and regular capacity development;
  - make sure quality and well-maintained tests and technologies are available;
  - implement and monitor the use of diagnostic safety guidelines, protocols and practices to ensure errors are minimized;
  - promote a culture of continuous learning and safety, and take action to address problem areas;
  - establish a conducive, collaborative and safe work environment free from distractions.
- Continually seek feedback from patients and their families and reserve space for advocates on advisory bodies.
- Celebrate diagnostic excellence within your teams.
Policy-makers and programme managersChampion diagnostic excellence in health policy
- Prioritise patient safety in policy, legislation and regulation:
  - ensure that appropriate guidelines and protocols to support diagnostic processes exist at a national level and are implemented;
  - provide the necessary budget, staff, training and access to tools and technologies for national health systems.
- Establish national collaboration mechanisms to sustainably engage stakeholders.
- Promote accountability through monitoring and evaluation mechanisms, and ensure health leadership prioritize transparency.
- Set up national knowledge-sharing systems and encourage continuous learning.
- Invest in research into diagnostic errors, patient harm and the development of diagnostic tools and technologies.
Patient organizations and civil societyAdvocate for quality and safe diagnosis
- Champion diagnostic safety in health policy and practice:
  - work with patients, policy-makers and health care leaders to build health systems that deliver correct and timely diagnosis;
  - facilitate patient advocacy and support their role in promoting and improving diagnostic safety;
  - work with policy-makers, academics, health care leaders, health workers and patients to help identify areas for improvement.
- Contribute to the development of educational and training resources for health workers and patients.
Diagnostics and medical devices’ regulators, manufacturers, innovators and managersInnovate for smart solutions and diagnostic excellence
- Drive research and development for diagnostic tools and technologies.
- Ensure diagnostic solutions meet the highest standards of safety, quality, and reliability.
- Create user-friendly products and instructions and provide regular training for health workers and patients.
- Collaborate with patients, health workers and health care leaders to build products tailored to the needs of end-users.
  
  Practical advice for stakeholders
  Patients, families and caregivers
  - Understand and engage in the diagnostic journey.
    
    Ensure you understand the diagnostic process, including the steps that you and your health care team will take to determine your diagnosis.
    
    Engage actively with your health care team by sharing accurate and comprehensive information about your symptoms and medical history from the start.
    
    Prompt your health care team to think comprehensively about alternative diagnoses, such as by asking “What else could it be?”
    
    Ask about the purpose, potential risks, alternatives and follow-up steps of any recommended diagnostic interventions.
    
    Keep track of your health, symptoms, medical visits and treatments.
    
    Be informed about the expected progression of your illness, potential danger signs and how to access care if your condition either does not improve or worsens.
    
    Adhere to prescribed treatment plans and attend follow-up appointments.
  - Ensure continuity, accuracy and validity of information.
    
    Ask your health care team for information and use reliable medical information sources.
    
    Follow up on the results of your diagnostic tests and proactively ask for the report; no news is not always good news.
    
    Don’t be afraid to seek a second opinion if you have any doubts or uncertainties about the initial diagnosis.
    
    Regularly check your health records to ensure that all information is documented, accurate and up to date.
  - Speak up with concerns about your diagnosis and care.
    
    Raise any concerns you may have about your diagnosis or the diagnostic process.
    
    Be aware of your rights (refer to WHO Patient Safety Rights Charter).
    
    When there is a concerning change in your or your family member’s condition, promptly escalate the issue to your health care team.
  - Contribute to learning and improvement.
    
    Engage in follow-up and provide feedback to your health care team about your diagnosis and treatment effectiveness.
    
    Help to improve the wider health system by reporting your experience and suggesting changes.
  Health workers providing clinical care
  - Establish a strong diagnostic foundation.
    
    Conduct careful and thorough history-taking and physical examination to ensure a solid foundation for correct diagnoses and to help personalize interventions according to patient needs, values and preferences.
    
    Know the diagnostic equipment and tools available in your facility or location.
    
    Engage in diagnostic stewardship by selecting and interpreting diagnostic tests based on evidence-based guidelines to accurately inform diagnoses and guide appropriate treatment.
    
    Carefully determine the value of diagnostic tests by considering the risks of overdiagnosis and underdiagnosis.
  - Strengthen diagnostic skills.
    
    Engage in continuous education and training to stay updated on the latest diagnostic reasoning theories, techniques, evidence-based practices and algorithms.
    
    Improve your clinical reasoning skills by engaging in reflective practice and using diagnostic simulations, checklists and tools.
    
    Practice self-awareness and regularly perform self-checks to identify and address any cognitive biases or errors in your diagnostic process.
  - Optimize communication and interprofessional collaboration.
    
    Communicate effectively within your health care team to ensure all relevant information is shared, understood and acted upon in a timely manner.
    
    Address diagnostic uncertainty by leveraging the knowledge, experience and skills across disciplines.
    
    Enhance your diagnostic calibration by seeking feedback from peers and patients.
  - Engage patients and families.
    
    Engage patients as active partners in the diagnostic process and decision-making by encouraging them to share detailed information, ask questions, raise concerns and provide feedback on care provided.
    
    Ensure patients understand both the diagnostic process and any available medical interventions through clear and empathetic communication.
    
    Provide patients with educational materials to support their involvement in shared decision-making and encourage them to review their medical records and test results.
    
    Educate patients about possible danger signs, how to report them and how to escalate concerns.
  - Leverage technology.
    
    Apply clinical decision support systems effectively.
  - Learn from errors and experiences.
    
    Report and learn from best practices, near-misses and diagnostic errors to continuously improve diagnostic practices.
  Health care facility leaders and managers
  - Establish systems, standards and processes to ensure safe diagnosis.
    
    Implement and monitor diagnostic safety guidelines, protocols and practices, including guidance on diagnostic stewardship and the use of structured communication tools during patient handovers.
    
    Ensure that efficient care coordination and reliable patient referral processes are in place and being carried out correctly.
  - Support the health workforce.
    
    Ensure sufficient staffing and resources to address key factors, such as fatigue and cognitive vulnerabilities, that can lead to diagnostic errors.
    
    Provide continuous training and educational resources to staff, covering critical areas such as clinical guidance and algorithms, clinical reasoning, teamwork, communication and the appropriate use and interpretation of diagnostic tests, particularly new technologies.
    
    Ensure the availability and proper functioning of diagnostic services to provide safe and appropriate diagnostic interventions.
    
    Implement technology-based solutions to support diagnostic reasoning, detect errors and enhance follow-up and tracking.
  - Create a conducive work environment.
    
    Ensure a work environment that is free from distractions and interruptions and is equipped with adequate resources.
    
    Encourage interdisciplinary teamwork and active patient engagement to facilitate accurate and timely sharing of diagnostic information.
  - Engage patients and families.
    
    Engage patients and families who have experienced harm from diagnostic errors in decision boards, advisory councils and safety committees to support the development of policies and programmes that enhance diagnostic safety.
    
    Ensure that patients have access to their medical records and that clear mechanisms are in place to follow up on test results.
  - Manage risk and promote continuous improvement.
    
    Cultivate a culture of safety and continuous learning through the promotion of openness and transparency.
    
    Conduct proactive risk assessments to identify potential diagnostic errors and implement measures to mitigate these risks.
    
    Collect and analyse data about diagnostic performance from multiple sources, including medical records, staff, and patients’ and families’ lived experience.
    
    Utilize data to rectify weaknesses and recognize examples of diagnostic excellence.
  Policy-makers and programme managers
  - Implement policies, legislation and regulation.
    
    Formulate and enforce policies, legislation and regulation that prioritize and support diagnostic safety within health systems.
    
    Ensure the availability of national clinical guidelines and protocols.
    
    Ensure health care facilities implement improvement interventions in areas with high rates of diagnostic errors.
  - Support the health workforce.
    
    Ensure adequate staffing to reduce workload and prevent burnout.
    
    Provide training for health workers to improve diagnostic practices and optimize consequent management as per patient needs and preferences.
    
    Improve access to specialized health workers and quality diagnostic tests.
    
    Strengthen and promote health information technology to support diagnostic reasoning, detect errors and enhance follow-up and tracking.
  - Facilitate stakeholder engagement.
    
    Create mechanisms, such as national committees, to facilitate collaboration among stakeholders involved in improving diagnosis.
    
    Support patient groups and organizations that advocate for diagnostic safety by providing recognition, resources, capacity building and opportunities for meaningful engagement in improvement initiatives.
  - Promote learning and continuous improvement.
    
    Ensure that health care leadership fosters a culture of transparency, accountability and continuous learning within health systems.
    
    Establish mechanisms to track progress and outcomes of diagnostic safety initiatives.
    
    Integrate the monitoring of diagnostic errors into existing reporting and learning systems, ensuring lessons are applied to prevent future incidents.
    
    Create a knowledge-sharing platform at national level to disseminate lessons learned, best practices and innovative solutions.
  - Research and development.
    
    Invest in research into diagnostic errors and related patient harm to support decision-making in policy and practice.
    
    Allocate resources to the development of diagnostic tools and technologies, ensuring they are safe, of high quality, effective and accessible to everyone.
  Tiles
  
  Patients’ organizations and civil society
  - Prioritize diagnostic safety in policy and practice.
    
    Raise awareness about diagnostic safety at all levels of the health system.
    
    Collaborate with policy-makers, health care leaders and health workers to shape health systems that support correct and timely diagnosis.
    
    Champion new legislation, regulations, policies and interventions to address diagnostic safety concerns.
  - Build the capacity of patient advocates.
    
    Build the capacity of patient advocates to effectively promote diagnostic safety and engage in improvement efforts.
    
    Contribute to the development of education and training resources related to diagnostic safety for health workers.
  - Contribute to improvement.
    
    Share patient stories of diagnostic harm and successful practices with researchers, academics, health care leaders and health workers to identify areas for improvement.
  Diagnostics and medical device regulators, manufacturers, innovators and managers
  - Innovate for diagnostic excellence.
    
    Champion innovation in research and development for diagnostic tools, technologies and practices.
    
    Ensure diagnostic tools and technologies meet high standards of safety, quality, reliability and are well maintained.
    
    Design user-friendly, interoperable diagnostic tools and technologies that seamlessly integrate into the clinical workflow to facilitate the diagnostic process.
  - Support health workers and patients.
    
    Support regular training for health workers and patients on the effective use of diagnostics and medical devices to maximize their impact.
    
    Create user-friendly IT solutions and AI-driven tools that assist in data analysis, pattern recognition and decision support for health care teams.
    
    Co-develop user-friendly patient portals and applications that provide patients with access to their health records and medical information, supporting patients understand their medical condition, know when to seek medical advice, and stay informed about their health.
  - Collaborate and gather user feedback.
    
    Collaborate with health care leaders, health workers and patients to understand their needs and challenges, ensuring that proposed solutions are practical and effective.
    
    Pilot new diagnostic technologies and gather user feedback to refine and improve innovations.
  - Research and development.
    
    Invest in research and development to drive continuous improvement in diagnostic technologies and practices, advocating for innovation in the field.