The Tokyo Declaration on patient safety A new partnership between health workers and patients to promote safer care. Kelsey Flott centre manager, Mike Durkin senior adviser on patient safety and leadership, Ara Darzi director Imperial College London, UK The 3rd Ministerial Summit for Patient Safety was held in Tokyo in April this year, with delegations from over 40 countries. The summit coincided with the publication of an Organisation for Economic Co-operation and Development (OECD) report, Flying Blind, which made an economic case for extending the patient safety movement to primary and ambulatory care, and further compelled international political interest in safety. 1 We can no longer afford to ignore the burden of poor safety, given the harm and cost to patients and healthcare systems it causes. The OECD has previously estimated that 15% of all hospital care is as a direct consequence of patient harm. The broader social and economic costs run to trillions of US dollars globally. Many of these harms are preventable and the costs of prevention strategies are dwarfed by the costs of harm. Improving patient safety in US Medicare hospitals saved an estimated $28bn (£22bn; €24bn) between 2010 and 2015. 2 At this year’s summit, patient harm in primary and ambulatory care settings was brought to the attention of many of the world’s leaders in healthcare policy and patient safety. Flying Blind reports that up to 25% of patients in these settings in high income countries experience harm—commonly from diagnostic error or delay and to adverse drug events. This increased to 40% among patients in low and middle income countries. The authors calculate that up to 50% of the global burden of harm from patient safety failures originates in primary and ambulatory care. Adverse drug events alone cause 100 000 hospitalisations per year in the US, 3 cost up to 2.5% of total health expenditure in Sweden, 1 and may account for 4% of all hospital capacity in the UK at an estimated cost of £654m to the NHS. 4 The impact of safety lapses across five common chronic conditions —diabetes, hypertension, heart failure, chronic obstructive pulmonary disease, and asthma—consumes an estimated 6% of all bed days across the 27 OECD countries. 1 The summit affirmed the importance of the foundational elements of patient safety: promoting just cultures within all health systems and developing the socioeconomic imperative for prioritising safety. Two days of debate culminated in a series of policy recommendations: the Tokyo Declaration on Patient Safety. 5 The declaration positions patient safety as a vital component of the global aspiration for universal health coverage. It sets out actions for ministers—chief among them a commitment to “high level political momentum” towards the delivery of safer care everywhere. Further actions include renewed support for the World Health Organization’s sustainable development goals and a proclamation to “align incentives, educate and train the healthcare workforce in patient safety, and engage patients and families.” Realising the declaration’s full potential will require advancements in three critical areas: leadership, infrastructure, and collaboration with patients and front line staff. Leadership that encourages a culture of openness around safety lapses is paramount, regardless of the maturity of a country’s health system or safety agenda, 6 7 and just, open cultures correlate with improved patient outcomes. 8 Incident reporting systems are already prevalent, 9 but they generate little in terms of learning. 10 11 Leadership is more than a commitment to cataloguing harm. 11 It means inspiring change and embedding patient safety in all healthcare activities. For political leaders it means promoting policies and regulatory targets that support rather than deter openness and learning. The story of Hadiza Bawa-Garba, a junior doctor who was struck off the UK medical register following involvement in a case of fatal harm, is a chilling example of how fear of retribution can stifle the transparency necessary to learn from complex safety incidents. 12 Up to date technological and information sharing infrastructures are essential for safe care. As we move towards a reliance on big data and digital information exchange, public trust in these systems depends critically on robust and transparent protection of sensitive data. 13 High profile failures of cyber security, such as the WannaCry attack in 2017, 11 have already eroded that trust, compounded by controversies over inappropriate sharing of NHS data. 13 Ministers and experts must now prioritise the interoperability of digital systems across health services. They must also communicate information about data sharing in a way that is accessible to everyone, so patients and the public know exactly how their data will be used. 14 15 Patient and public involvement in the safety agenda was a leading theme of the summit, and the resulting declaration calls k.flott14@imperial.ac.uk For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2018;362:k3424 doi: 10.1136/bmj.k3424 (Published 8 August 2018) Page 1 of 2 Editorials EDITORIALS