PATIENT SAFETY CULTURE: CHALLENGES IN ADVERSE EVENT MONITORING AND A LOOK INTO THE FUTURE

Abstract

The concepts of patient safety and adverse events are closely interconnected. Adverse events are defined as incidents, circumstances, or actions that could have caused or did cause harm to a patient. They are considered a key indicator of the effectiveness of patient safety culture within a healthcare system. Ensuring patient safety is an integral part of healthcare delivery. Although adverse events are often unavoidable, research suggests that between 20 and 50 percent of such events in healthcare institutions could be prevented through systematic prevention measures.

Globally, between 4 and 25 percent of patients experience adverse events in healthcare settings. According to the World Health Organization, one in ten patients in high-income countries is affected, while in low- and middle-income countries approximately 134 million adverse events occur annually. These figures highlight the importance of effective monitoring systems.

Lithuania adapted a mandatory adverse events monitoring model. Healthcare institutions are required to register, analyze, and confirm adverse events annually. Data are analyzed by the Hygiene Institute, while a national expert commission coordinates patient safety improvement. Since 2021 the national Public Health Monitoring Information System is used for registering adverse events.

The number of reported adverse events has steadily increased from 2020 to 2025; this trend likely reflects improved awareness and reporting rather than declining safety. However, underreporting remains a significant challenge, as many institutions only formally participate but do not register adverse events. Recent feedback surveys identified the need to simplify reporting procedures, enhance training, and strengthen cooperation. Future plans for 2026–2030 focus on improving the monitoring system, fostering a stronger safety culture, and expanding interinstitutional collaboration to reduce preventable harm.