 Mae'r ffyrdd ymddangos yw'r gweithio, ond y gallwn ei wneud eich holl yn i gynnwys yn y cyflawn ac yn y bwysigol'r ffyrdd yn ei gael. Mae'n bod yn unig o'r ffordd ymddangos bod ymddangos ei fod yn gwneud yn ymddangos i'r wych yn ymddangos ymddangos, ac yn ymddangos yn ymddangos ymddangos ac yn ymddangos i'r wneud ac yn ymddangos i'r gweithio ar gyfer ymddangos a ddod yn ymddangos i'r gweithio Morning Mark has a result of listening it will be there with you as well of all the conversations that I had during the pandemic one more than any other keeps coming back to me. She said to me, If only I could have held my mother's hand, as she lay dying. Just for that one hour, and mum wouldn't have died alone. i chi dweud o'r ysgol iawn i'r ffordd o'r ffyrddion am dyddion a fyddwch yn eich ffordd o'r amddangos i'r ffordd o'r ffordd. Fy oedd y bydd y bydd y bydd yn oed yn granol iawn i'ch bod ei bydd, y dynion, yn y ffyrdd hynny'n ddweud o'r ffordd o'r ffordd o'r ffordd yn dweud o'r ffordd. Mae'r ffordd yn fwm eich gwirionedd o'r ieddaeni. Ym ym 19 yw ynglynig yma yn y pethau'r ysgrifennu o'r hynod. a mae'n gwneud o'r pergylchedau sy'n gweld yn ymgyrch yn ymddeud hynny. Fy nid oedd ymddynt arall? Fy ymddynt ymddynt ymddynt yn ymddynt? Ymddynt ymddynt arall a'r cyfnodol? Ymddynt y pandemig ar gyfer yw'r modau, ymddynt ymddynt yn ymddynt yn ymddynt yn ymddynt yn ymddynt, ymddynt yn ymddynt yn ymddynt yn ymddynt yn ymddynt, gyda gyd-dylch ar y bydd gweithio a gweithio'n gweithio'n gweithio. Ymddynt ymddynt ymddynt sy'n gweithio i siwll ac i cael debyg at Oeddon, ymddynt ymddynt yn yr Oeddon, mae'n gwneud ymddynt yn gyfrif dormirau gweld yn siwll o gyffredig cyfnodol bydd oedd angen iawn wychon i gyfnodol. Mae hyn yn cael ei ddechrau sydd wedi ei ddyn nhw'n gwneud yn Blwyslynyddiol Mae'r Fudip sydd a nhw'n gwybod y dweud yn y ddefnyddio ar gael. Ond rydyn ni'n gael pethau allanieddau ar gael ei ddweud yn llawer o'r dynnu'n ddeithasol a'r ddeithasol i'r ddeithasol i'r dynnu'n ddweud. Oherwydd, rydyn ni'n ddweud ar y ddiwedd y ddweud yn ei ddeithasol i'r ddweud ar y ddweud. Yn ystod, yn ynghyd y 2020, y ddweud y system hefyd ar y ddechrau o'r ddechrau cymaint o'r ddechrau Llywodraeth, sydd wedi bod yn meddwl i'w rhesiliad arno. Felly, wrth gwrs, rhesiliad yw'r ddechrau i ddefnyddio bach ac ydynt yn ddechrau'r ddechrau cymaint. Bydd ydynt yn ddechrau'r ddechrau ar gweithio'r ddechrau cymaint. Felly, mae'n ddysgu'r ddechrau i ddechrau cyfnodd o golygu o'r ddechrau, cyfnodd o wneud eich gweithio'r ddechrau, Sometimes, when you have taken this as a role, you can use it to protect yourself and re-create the impact of risks and threats to their safe operations. There are many many definitions of resilience, formal definitions. But I quite like the informal ones, which embodies the idea that when confronted by a serious threat to normal functioning organizations that are resilient will bend, they won't break. ydy'n gael i gael i gael i'r newid cyfnodau byddurol. Mae'r gweld yn ddweud i'w gweithio'r hwn yn gweithio'r pandemig, yn dweud o'r cyfle ffasil o'r gweithio'r pandemig, yn dweud o'r gweithio'r gweithio'r pandemig, yn dweud o'r gweithio'r systeimleddau i'r gweithio'r ffaith yn yw'r gweithio'r gweithio'r gweithio'r pandemig. Firstly failure over the years to develop world-class infection prevention and control policies and practices at health facility level led to unsafe environments in which patients and health workers' lives were put at risk and indeed many lives were actually lost due to that. The simple but crucial lesson of the first COVID crisis and of the Ebola outbreak in West Africa is that the impact of viruses with pandemic potential is amplified if they're allowed to spread within health facilities. Those lessons were not learned in the pandemic planning phase or in building resilience facility level, another feature that should have been an integral part of patient safety programs pre-pandemic. So the relevance of resilience was very different in the poorer countries of the world. Many of their health systems were already fragile pre-pandemic, but the additional harm caused by pandemic-related loss of services created a double jeopardy effect in settings with poor infrastructure, shortages of skilled staff and limitations in access to primary care and specialist services. So the COVID experience of those countries have also taught us another lesson. The traditional idea that patient safety only matters at the point of care was shown to be much too narrow away of conceptualizing patient safety with consequences of harm generated at the population level. For example, in 2020 compared to the pre-pandemic year 2019, the key measure of coverage for essential childhood immunization fell from 86% to 83%. Though this consequential harm may only sound a small percentage, but in reality it represented the loss of more than a decade of progress in global immunization coverage. Hundreds of thousands of children across the world were left unprotected and were only just starting to catch up. Another example, for example, a modeling group convened by WHO and UNAIDS during the pandemic, estimated that a six-month disruption of antiretroviral therapy for 50% of patients in sub-Saharan Africa would lead to an excess of half a million HIV-related deaths in a year. So these sources of avoidable harm in lower-income countries were partly created by closure of facilities and services to reduce spread of the pandemic, but they were also caused by repurposing of the public health workforce in low-income countries. It was repurposed to fight COVID-19, and then it was subsequently repurposed again to plan and deliver a COVID vaccine program. And as you well know, in many countries of the world there is only one public health workforce. So if staff are moved away from their jobs to deal with an all-consuming emergency like this, then they're not able to provide continuity of essential health services. And then looking more broadly across the world, new needs and demands for care surged as a result of COVID-19. There was an impact on people's lives, their economic circumstances and their well-being. The desperate need in many countries amongst adults, adolescents and children now for mental health services has rocketed in many countries of the world. So I used the term earlier, consequential harm, to describe these phenomena. So it's almost like the virus acted like a pebble thrown into a calm lake and a ripple effect developed. So it wasn't just the direct consequences of the virus in the limited areas where it was operating. It was a much wider effect, spilling over to population health and societal impact in a much, much bigger way. Another key traditional source of risk to patients is the phenomenon of transitions of care. You'll be well familiar with the many pre-pandemic examples of how patients crossing the care boundaries are exposed to additional risk, sometimes called handovers. But this effect was very prominent during the pandemic, notably amongst elderly and vulnerable patients who were transferred between hospitals, care homes and the community. So in the fast-moving pandemic context, decisions like testing and transferring in that area weren't particularly carefully thought through, or were dictated by capacity problems, needing to get patients out of hospital to make space for other ones, meant that they were transferred without due clinical process. And this was shown in a number of countries by the grim long-term mortality statistics as a percentage of overall deaths for people in nursing home care. Why should we be surprised or why should we have been surprised? Because transitions of care are part of our or should have been part of our thinking in patient safety and should have received attention along with the other areas known to increase risk in pre-pandemic times. So there wasn't much thinking about patient safety in pandemic planning, the pandemic planning that preceded COVID-19. If anyone had thought about the implications of a pandemic for patient safety, there are two other conclusions that would have been obvious. First, existing patient safety incidents would continue to occur and some would become more likely because of the pressurised staff and clinical environments created by the health emergency. And second, new kinds of patient safety incidents would emerge. And this is exactly what came to pass and the data show this and are confirmed by the observations and experience of the patient safety community. For example, pre-pandemic medication error and avoidable error from medication have made a relatively high proportion of the incidents reported. And many examples of high risk medication situations were created or exacerbated by the pandemic, diagnostic errors as well. And we heard quite widely of a tendency in places that had patient safety reporting systems to let those systems go into abeyons during the pandemic because there wasn't time to do the reporting investigation. Understandable in one way, but one of the principle tools for protecting patients was abandoned at a time where probably it should have been retained and strengthened to help with the response. So as health systems around the world struggled to provide care and support for large numbers of acutely ill patients experiencing the effects of the new pandemic virus, the high volume, high pressure context for the delivery of services together with the need to reduce transmission created an entirely new operational reality. There was a new normal too for patients and families. Doors were closed, service pathways were blocked, care continuity was fractured and treatments were cancelled or delayed. And early reports from our patient safety network initially largely from high income countries spoke of the interaction between providers and patients suffering and I quote, disastrously due to diagnostic confusion, lack of access to needed healthcare and the exclusion of families from health and healthcare facilities for infection control reasons. And the conversation I related at the beginning of my presentation is typical of the traumatic circumstances of the large numbers of end of life situations occurring without the presence of family and friends that were arising in acute hospitals and nursing homes as the severity of COVID-19 exerted its toll. But the fracture in the role of patients and families in patient safety during the pandemic was even more profound. Patient and family engagement as you know and as you've heard in the meeting today has been an important part of the WHO's work. So too in many member states and their health systems, the WHO patients for patient safety program, which was established when I founded the World Alliance for Patient Safety in 2004 has provided strong leadership and advocacy over the years in policymaking and planning. And it's become a key source of expert advice on when and how to involve families in patient safety work. So as the pandemic unfolded, patients and families who have been part of the global and national patient safety programs have asked why given that patients and families were being so heavily impacted by the disease, were they not part of all decisions at all system levels even during a crisis like this. This happened in some health systems and organisations, but it does seem to have only happened in a minority. Families are clearly positioned as partners or potential partners in care and in an emergency like this they can ensure safe care, they can try to ensure ethical decisions for example consent for those who are unable to give consent themselves or who are at the end of life. They play a key role in providing continuity of care through those transitions of care and handovers which can be high risk situations. They can help in making assessments of acutely ill relatives in the home or community when there's no face to face medical help available and when rapidly assembled triage protocols are being operated remotely. So very strong views emerged on visitation policies and practices that were put in place as part of facility based infection control procedures. Patients and family members criticised what they called blanket no visitor policies as not recognising the key role of family caregivers. So I've only had 15 minutes this afternoon to cover this area but I wanted to touch on just some of the areas of patient safety that the pandemic has thrown light on and there are others. But although I've mainly focused on the problems there was much excellent work done and great innovation around the world as health systems clinicians and scientists fought back against this unprecedented onslaught and we need to learn from that as well on the whole team working became much more cohesive and we saw that right across the whole world. And there are opportunities there in which silos were broken down to make sure that the silos don't drill down again and create the sort of fragmentation that is problematic across all areas of health care particularly in an area like patient safety. So at the end of the day I feel that the pandemic experience has helped us to see how deeply pre-existing patient safety concepts, practices and cultures were embedded in our existing health systems. It was somewhat disappointing that our work over the last two decades wasn't a dominant part of the response culture at a time of the most intense pressure for health care around the world. But leadership and advocacy of a group like this is absolutely vital if the next global and national pandemic plans are to contain a substantial chapter on patient safety in pandemics and as a patient safety community we have a lot to contribute. So finally thinking back to the beginning of my presentation I think never again should we see a technical communicable disease control set of decisions drive compassion from the centre of the care that we give to our patients. That's one big thing that needs to change and one big lesson that needs to be learned. Thank you.