World Patient Safety Day (WPSD) marked each year on 17 September, calls for global solidarity and concerted action by all countries and international partners to improve patient safety. This year’s slogan, “Patient safety from the start!”, emphasizes the urgent need to act early and consistently to prevent harm throughout childhood, and yield benefits across the life course.
Authored by: Mebrahten Gebremariam
There is no doubt that providing healthcare is a lifesaving service. Such a unique and noble service deserves to be honored and regarded as sacred. And, healthcare professionals, alongside the tools they use, including medications and medical devices, play a pivotal role in saving lives.
Yet, medical services are not entirely free from error. Even with the best intentions, mistakes and unsafe practices can occur, leading to preventable harm.
Patient safety is a global concern. The World Health Organization (WHO) states that “Around one in every 10 patients is harmed in health care and more than 3 million deaths occur annually due to unsafe care.” The risks of patient harm in countries like Ethiopia are worse, where “…as many as four in 100 people die from unsafe care.”
This is why patient safety is a critical component of quality care in healthcare services. It is the key to ensuring that people receive care without harm, as well as to protecting patients from avoidable injuries, complications, and deaths.
Since 2019, the WHO has designated World Patient Safety Day (WPSD), observed annually on September 17, to emphasize the importance of ensuring patient safety in healthcare practice. To frame health safety issues clearly and communicate them effectively, each year’s WPSD is marked with a specific theme and slogan to guide global awareness efforts and advocacy actions.
The 2025 theme is “Safety Care for every newborn and every child!” emphasizing “Patient safety from the start!”
Participants of the WPSD2025 marked at Ayder Comprehensive Specialised Hospital, Tigray, Ethiopia
Under this theme and slogan, Ayder Comprehensive Specialized Hospital, in collaboration with the Tigray Regional Health Bureau and MARCH Research Centre-MU, commemorated the day through a research-informed discussion forum. Five topics and case studies relevant to the 2025 theme were presented, each revealing actionable insights drawn from global, national, and institutional evidence that fortifies the need to strengthen patient safety practices in our context.
The presentations included early learnings from the ongoing implementation research interventions by the NEST360 and SLL360 programs, particularly for biomedical technicians (BMETs) and quality improvement (QI), that highlighted relevant patient safety concerns.
NEST360/SLL360 Quality Improvement (QI) initiatives: implications for patient safety
Dr Atsede Gebrekidan, a pediatrician from Ayder Comprehensive Specialized Hospital and QI Lead with NEST360 and SLL360, shared insights drawn from the program’s ongoing QI projects. She highlighted the implementation research projects being carried out under the MARCH Research Center at MU, including the NEST360 and SLL360 programs. She emphasized the benefits of QI projects in ensuring patient safety, including decreases in neonatal mortality. She also highlighted an ongoing blended mentorship program that brings clinicians, data science, biomedical equipment, and quality improvement (QI) experts together to ensure quality care across involved health facilities.
Dr. Atsede Gebrekidan, presenting.
Dr Atsede described a particular QI project that was implemented in the labor and delivery ward of a hospital in Ethiopia. At baseline, the coverage of infection prevention and control (IPC) practices at the hospital’s Obstetrics and Gynecology department was extremely low at 43%. To improve patient safety, her team of experts is working to improve IPC coverage to 90%, and they have launched an ongoing QI initiative to achieve this goal.
Dr Atsede underscored that safety is one of the seven dimensions of any properly designed QI intervention. She emphasized the important role understanding QI projects and principles plays in establishing effective safety strategies within the institutional systems.
She said, “QI should not be perceived as alien to what we do as clinicians; instead, it should be seen as an integral part of our daily care provision.”
Incorporating QI practices into everything providers do at the individual and institutional levels develops a culture of improving patient safety. In Ethiopia, to broaden the culture of safety, the country has joined the WHO network of Patient Safety member countries, and Ayder Hospital has been selected as one of 23 hospitals to serve as hubs for patient safety training in Ethiopia. This commitment to patient safety by Ethiopia shows a commitment to patient safety across the individual, institutional, and now country levels.
To err is human, to prevent is a responsibility.
Maintaining patient safety requires continuous learning and improvement. According to Hailay Teklu, Hospital Quality Head at Ayder Hospital, designing and sustaining QI projects can help prevent hospital-acquired infections, medication errors, incorrect and delayed treatment, and falls, which represent one of the most prevalent patient safety incidents in hospitals in Ethiopia.
Mr. Hailay Teklu, presenting.
He also discussed how important it is to monitor and maintain accurate patient safety records. He noted a case where medical reporting of safety errors was impacting patient safety. The inconsistency in reporting across all wards of the case study hospital created a gap in understanding about the state of patient safety within the institution, and no room to learn from challenges and improve.
He explained that although safety errors are likely to occur in healthcare, it is important to remove the “shame and blame” from reporting them accurately. Because in a systems approach to patient safety, recording errors is the first step in addressing and resolving them.
Rather than a culture of blame, it is important that errors are recorded because of identified underlying causes. This practice places emphasis on maintaining accountability at all levels of an organization, ensuring meaningful improvements in patient safety without “blaming” individuals.
With the unwavering support of the regional health bureau and the MARCH Research Center’s lifesaving interventions, including the NEST360 and SLL360 programs, the case study hospital has been encouraged to improve its patient safety culture and record errors and their root causes. As an encouraging move, the hospital has started patient safety surveys among its staff, instituting an important next step for systemic improvements in a patient safety culture within the hospital.
Medical Devices: Lifesavers or Sources of Hazards?
From simple tools to the advanced ones, medical devices can either save lives or, if misused, cause harm ranging from disability to death. According to the data presented by Atakilti Yerga, a Biomedical Engineer at MARCH Research Center-MU, the poorly maintained and under-monitored medical devices found in the region where the case study hospital is located could do more harm than good.
Mr. Atakilti Yerga presenting
Additionally, an alarming knowledge and skills gap exists among healthcare providers regarding the usage, handling, and maintenance of each device. A shortage of biomedical technicians (BMETs) is also a concern for safety.
In this context, the NEST360/SLL360 BMET track interventions are emerging as a beacon of hope by building the capacities of BMETs through in-house training and hands-on, onsite blended mentorships that take IPC practice and patient safety into consideration.
Immediate attention to this gap from policymakers to practitioners is needed to increase the number of trained BMETs to maintain and monitor equipment, increase training to support proper use of equipment and improve equipment-related safety, and minimize device-induced harm.
Experiences from the Multimodal IPC Project in a Case Study Hospital
According to the WHO 2024 Global Report on Infection Prevention and Control, healthcare-associated infections (HAIs) are among the most frequent adverse events that occur in the context of health service delivery. “On average, out of every 100 patients in acute-care hospitals, seven patients in high-income countries (HICs) and 15 patients in low- and middle-income countries (LMICs) will acquire at least one HAI during their hospital stay.”
While the WHO’s data sounds concerning, it should be examined within the context of the immediate aftermath of the Tigray war, which is expected to impact patients and increase HAIs. The speaker outlined the context of the war and siege that ravaged Tigray from the perspective of HAIs.
Reports, including a 2023 assessment by WHO, show that 86% of the health facilities in Tigray have been fully or partially damaged by the devastating war and siege that spanned from November 2020 to November 2022. During that time of unspeakable suffering, there was no access to a supply of medications and medical devices, and no salaries for health workers for 20 months. Additionally, there was no access to their savings due to the total collapse of the banking system and a total communications blackout.
And, the case study hospital was no exception. Its infection prevention and control (IPC) practice was almost non-existent. Dr Hailemariam Gebrearegay, a pediatrician at Ayder Hospital and Head of the Department of Pediatrics and Child Health, presented evidence from the post-war context, starting from February 2024. In the neonatal intensive care unit (NICU), the prevalence of healthcare-associated bloodstream infections (HA-BSIs) reached 33.3%. This means more than twice the rate reported by WHO in the context of low- and middle-income countries (LMICs), which was 15%.
Dr. Hailemariam Gebrearegay, presenting.
Then, Dr Hailemariam and his colleagues, in consultation with the hospital management and international expert collaborators, implemented a multimodal infection prevention and control (IPC) project. As an interventional study, they applied the WHO’s IPC guidelines and trained healthcare providers on IPC practices, resumed alcohol production, and introduced a surveillance system whereby neonatal deaths were properly monitored and reported. Additionally, there was a continuous virtual discussion with international collaborators and IPC experts, who provided critical guidance and support.
The results were quite remarkable following the introduction of this program! Hospital-associated bloodstream infections (HA-BSIs decreased by 78% and the neonatal mortality dropped by 77%. Let’s see what this means. Cases of hospital-associated bloodstream infections (HA-BSIs) decreased from approximately 333 infections per 1,000 admitted patients to just 74 per 1,000 within two months and 96 episodes per 1,000 by the end of the study in June 2024. And, newborn deaths also fell sharply, by more than three-quarters. At the start, 29 out of every 1,000 admitted babies died, but this improved to 17 per 1,000.
The dedicated staff, leadership, local resources, and international knowledge sharing (done virtually) played a pivotal role in making success happen in the hospital that was part of the case study. Dr Hailemariam offered this as an encouraging and clear lesson about the importance of IPC practices and patient safety, and how much progress can be achieved.
Role of incorporating family in newborn care units in mitigating safety concerns
The WHO’s World Patient Safety Day briefing document notes that “Children, parents and families play a vital role in making health care safer. Yet, they are not always invited to participate, and their voices are rarely properly heard, which can lead to harm.”
Znabu Hadush of the MARCH Research Center at MU presented on the significance of incorporating families in newborn care units, thereby mitigating safety concerns. Whereas the new newborn care model encourages family involvement in the care process, our long-standing medical practices often restrict this participation chiefly due to concerns about infection risks.
Znabu Hadush, Presenting.
Znabu emphasized the responsibility of healthcare providers to manage the prevention of infections without excluding families from participating in their babies’ care. He explained that a paradigm shift is necessary in approaches to newborn care services. Family integration not only improves quality and ensures safety, but also upholds the rights of both the neonate and their family. Patient safety can be strengthened in this context through open communication, which in turn fosters trust and shared decision-making.
Additionally, family integration eases the burden on the healthcare providers. Unlike a single nurse trying to attend to ten newborns, a mother can be fully dedicated to attentively caring for her own baby. This practice also makes the safety culture more sustainable, as the family gains the knowledge and skills from that very experience.
Reflections
Following the thought-provoking presentations, participants shared enriching perspectives from their day-to-day clinical practices. They shared key challenges and solutions they routinely see in their endeavors to provide safe care to their patients.
Dr Abraha Gebreegziabher (top) and Prof. Haftu Berhe (bottom)
Dr Abraha Gebreegziabher, Chief Clinical Director of Ayder Comprehensive Specialized Hospital, and Prof. Haftu Berhe, Academic and Research Director, reaffirmed their commitment to institutionalizing patient safety and advancing such discussions within broader scientific forums.
As I write this piece, the hospital I work in has started distributing a survey on patient safety practices among its staff; a promising move toward walking the walk on ensuring patient safety.
As one former WHO Director-General, Dr Margaret Chan, once said, “Patient safety is not a luxury; it is a fundamental right.”
With that in mind, the fundamental right to patient safety, I hope you will join me in making it an imperative. Together, we must ensure that we as healthcare providers stick to the Hippocratic Oath, a moral compass for their clinical decision-making and ethical practice. Its enduring principles, especially the ‘do no harm’ one, if upheld fully, protect that fundamental right: patient safety.
“Safety Care for every newborn and every child!”
“Patient safety from the start!”
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