More with less: Low-tech solutions to patient safety problems

“Sometimes this high-tech world calls for low-tech solutions”—Christopher Moore

Approximately 1 in 10 patient experiences harm in healthcare worldwide. Much of the burden falls on low- and middle-income countries (LMICs) where nearly 4 in 100 people die from unsafe care. ¹ The cost of treating those harmed is enormous—the direct cost approaches 13% of a high income country's total health expenditure and may be greater for LMICs. When indirect costs such as lost productivity are also considered, the global economic burden is at least $1.5 trillion annually.^2,3 Diagnostic errors alone are estimated to consume 1.8% of GDP in developed nations, and LMICs may be equally affected. ⁴

While medical technologies have demonstrated efficacy in reducing harm, many have high economic and operational costs, placing them out of reach for resource-constrained health systems. Implementing high-value, low-cost solutions to reduce preventable harm is therefore critical to improving patient outcomes while minimizing the economic impact of harm.

The market is full of solutions that are effective but unaffordable to many if not most organizations. To prevent pressure injuries, a health system may purchase smart mattresses that monitor and redistribute pressure. This technology, however, is costly to acquire—approximately $7000 per mattress, and thousands more to maintain and train staff to use correctly. ⁵ Similarly, features of the electronic health record (EHR) such as computerized provider order entry for prescribing medications and clinical decision support have significantly reduced medication prescribing error. However, implementation requires an EHR, workflow redesign, and significant funds to purchase, and to maintain and train staff. ⁶

High-tech solutions to prevent hospital-acquired infections also fit the bill, each carrying substantial acquisition, maintenance, and training costs. Ultraviolet disinfection robots can sterilize a hospital room in 10 minutes ⁷ ; hydrogen peroxide aerosolization devices can decontaminate surfaces and equipment ⁸ ; and smart remote video monitoring systems can audit and reinforce hand hygiene compliance. ⁹ Sepsis early-warning systems powered by AI can analyze continuous patient data to identify infections early but require integration with electronic systems, ongoing tech support, clinical workflow adaptation, and training for decision-making. ¹⁰

These technologies cannot be thoughtlessly plugged into LMIC institutions where spare parts and specialized technicians are sparse, electrical supply is unreliable, and budgets are small and can depend on irregular donations. Furthermore, resource constraints are universal. Recent belt-tightening at the World Health Organization (WHO), sweeping cuts to US federal agencies, and budget pressures at academic medical centers remind us that even high-income countries must do more with less. Low-cost patient safety solutions are needed across the income spectrum.

However, there are relatively few publications on this topic.

In this paper, we provide examples from members of our international editorial board on “low-tech” patient safety solutions they have encountered that require minimal resources. In general, inexpensive interventions offer value because they are feasible, scalable, and sustainable even when technical support, budgets, and infrastructure are limited. Many of these examples focus on simple process changes, more effective communication, and better use of existing resources rather than new technology. We have grouped these into categories: communication tools; standardized procedures; visual tools; empowering staff and patients; streamlining; and lower-tech solutions. We also discuss implementation of these strategies.

Structured communication and communication tools

Ineffective communication has been reported by the US Joint Commission to be the most common cause of adverse events. ¹¹ Structured communication processes and tools can improve communication of important information during handoffs, such as abnormal test results. In this issue of the Journal, Do and colleagues recommend that public hospitals in Vietnam implement intervention programs to improve teamwork and communication. ¹²

Handoff procedures are a simple way to summarize patients’ condition and facilitate continuity of care. Dr Bellandi reported on the usefulness of structured handoffs as part of an intervention bundle to improve birth outcomes in 34 facilities in Kenya, Tanzania, and Uganda. ¹³ For the referral of pregnant women from community care services to hospitals, structured paper or electronic-based handoffs were an effective method to communicate risks that had been identified.

Dr Koizumi noted that in Japan, physicians sometimes overlook the radiologist's CT or MRI reports, which can lead to missed or delayed diagnosis. Instead of just noting it in the digital text, the radiologist asks the ward clerk to hand-deliver a gentle reminder letter. This “simple but sophisticated” strategy alerts clinician to subtle incidental findings, like tiny lung nodules. Critical findings would be physically circled or underlined with a colored marker in the copy of the report.

At higher levels of the system, WHO, national and regional bodies, and patient safety organizations can produce alerts that are distributed widely. For example, the Japan Council for Quality Health Care runs a national reporting and learning system. Dr Ushiro reported that the system issues monthly alerts on safety problems to raise awareness of health care professionals nationwide.

Standardized procedures, including checklists

Ensuring patient safety through system-level interventions is a cornerstone of quality health delivery, particularly in high-risk areas like medication management and communication of critical diagnoses. Structured standardization and process optimization can yield improvements in safety and quality. Dr Sibal explained how targeted, low-cost quality improvement initiatives led to significant clinical benefits in his health system in India. Insulin-related errors, which are common in prescribing and administration, were reduced by over 50% with standardized prescription practices and a mandatory double-check system. Improvements in critical laboratory value reporting were achieved by implementing clear protocols that included defined timelines, verification processes, and read-back communication.

Tools provided by WHO and others have been developed for infection control, safe surgery, safe childbirth, medication safety, and prevention of falls and pressure injury, to name a few. ¹⁴ Complex guidelines operationalized as checklists have been shown to improve patient safety. Tommaso Bellandi described a program that used the WHO Safe Childbirth Checklist to help prevent morbidity and mortality in mothers and neonates in Kenya, Tanzania and Uganda^13,15 Use of the checklist can help organize safer practices in delivery units through better teamwork and focus of limited resources on the critical steps of care. It can also improve patients’ experience by active and transparent engagement before, during, and after delivery.

Similarly, Dr Letaief described a structured triage system for maternity wards. This employs standardized triage tools developed by WHO such as the Interagency Integrated Triage Tool to prioritize care for women based on the severity of their condition on admission.^16,17 By ensuring that those with life-threatening complications receive immediate care, this reduces delays, optimizes resource allocation, and improves survival rates. ¹⁸ The tool requires minimal financial investment, relying primarily on adherence and team communication, making it feasible in both high- and low-resource settings.

Basic documentation is lacking in many LMIC settings and the monitoring and recording of vital signs can be erratic. However, studies have demonstrated that co-designing and standardizing documentation, combined with audit and feedback can produce marked improvements in monitoring. ¹⁹ Making even these improvements is immensely challenging in low resource settings and requires sustained, collaborative engagement over several years but can produce substantial benefits. English and colleagues have shown that clinical networks and data systems can be developed in LMIC using the principles of learning health systems, which support research and contribute to strengthening of health services and research systems. ²⁰ And, as described by Dr Pronovost, once documentation has been routinized, it is possible to put into place simple management and accountability systems. ²¹

Physical tools and visual aids

Simple physical tools and signage can provide solutions in LMIC that are low-cost and highly adaptable to local context. Dr Strametz described experience from a partnership project with a hospital in Malawi. ²² One intervention was patient wrist bands for correct patient identification which reduced mix-ups and treatment errors. An important lesson from this work was that the wristbands were sourced from a local festival organizer rather than the medical supply chain. This eliminated intermediaries, allowed direct communication of preferences to meet the hospital's specific needs, and reduced costs. The project also applied paper-based peri-operative safety checks based on the WHO Safety Surgery Checklist. ²³

Simple visual aids from WHO—exemplified by the “5 moments for hand hygiene” poster for the Clean Care is Safer Care campaign—raised global awareness of hand hygiene. ²⁴ The “5 moments for medication safety” graphic followed this path for the Medication Without Harm campaign. ²⁵ The Safe Surgery Checklist played a similar role for the Safe Surgery Saves Live campaign and today appears in operating rooms around the world. ²³

At the community level, the Community Score Card (CSC) offers another inexpensive yet transformative approach to improving patient safety and quality of care. ²⁶ By engaging both service providers and community members in a structured dialogue, the CSC facilitates joint identification of challenges, prioritization of solutions, and monitoring of progress. WHO-supported initiatives and partner-led programs have demonstrated that CSC implementation strengthens accountability, improves responsiveness of health services, and fosters trust between communities and health facilities. ²⁶ Importantly, the CSC relies on participatory engagement and organizational commitment rather than advanced infrastructure, making it scalable and sustainable at multiple levels.

People power—health care workers and patients

Drs English and Vincent stress that adequate staffing is crucial for delivering adequate care quality, citing the example of ensuring enough nursing time to care for sick newborns in Kenya. Over the long term, increasing nurse staffing is essential for improving care and for making effective use of new technologies. ²⁷ In the short-term, the most effective interventions may be aimed at stabilizing the existing system to provide more reliable basic care, ease pressure on staff and provide a foundation for further improvements. Task shifting shows promise in settings where nurses simply do not have time to provide a basic standard of care. For example, Kenya faces a critical shortage of nurses in neonatal units, impacting care provision for small and sick newborns in public hospitals. As a way of managing the workload, nurses in these understaffed neonatal units prioritize tasks and care for critical babies and informally share or shift tasks to other cadres working in neonatal units and with caregivers. ²⁸ Introducing ward assistants to undertake basic non-clinical tasks can support both caregivers and nurses in improving aspects of care quality. Nurses view ward assistants as a valuable workforce addition that can perform basic non-clinical roles under supervision, and this complements efforts to increase time for direct patient care. ²⁹

Institutional budgets place limits on the capacity to hire workers. There are potential challenges in training health workers to adopt new routines, and to train local community members to provide non-clinical assistance. However, in both high- and low-income settings, engaging patients and caregivers in their own care has proved to be an effective way to improve safety. In addition, Dr Strametz advocates for engaging local safety champions to adapt interventions to a hospital's specific needs as an important and inexpensive strategy.

Streamlining and eliminating waste

Drs Thomas and Pronovost emphasize eliminating waste as an ideal low-cost way to improve safety. More specifically, it is useful to review health care providers’ workflows to reduce unnecessary steps. Ensuring that certain spaces, such as pharmacies are well-organized can reduce waste and reduce errors. Dr Sibal points out the important role of formulary rationalization and elimination of duplicate products as part of efforts in his health system to increase insulin safety. Dr Pronovost cited a toolkit employed at University Hospitals in Cleveland, USA to reduce waste. ³⁰

The Choosing Wisely campaign was created in 2012 in the U.S. to improve health care quality and reduce tests and treatment that offer little or no benefit to patients. ³¹ Since that time, it has spread globally. The campaign publishes materials to help reduce use, and encourages conversations between patients, families and physicians. Professor Koizumi noted that Choosing Wisely has gained traction in Japan lately amid financial pressures on their healthcare system, and that the initiative helps to reduce both patient risks and costs.

Lower tech solutions

“Tech-light” solutions can be developed using existing technologies and do not require new or expensive equipment. Mobile phones are now ubiquitous, even in low-income countries, and their use for mobile health (mHealth) expanded worldwide during the COVID-19 pandemic. When used as medical devices, smartphones can help narrow the gap in diagnostic quality between low and high income countries. Smartphones have been used to screen for or diagnose cardiovascular diseases, eye diseases, sleep apnea, depression, and a host of neurological problems.^32,33Although these technologies are still maturing, they hold promise to reduce diagnostic errors.

Dr Mair describes a “Manage Meds” app that is free and allows people in Scotland to keep their own lists of medication and access relevant information. This includes information to support shared decision-making, help manage medications during illness, and identify medication problems to discuss with a healthcare professional.

A component of Bellandi's project in West Africa was the introduction of inexpensive point-of-care obstetric ultrasound (POCOUS). This tool has significantly increased the number of ultrasound scans performed during prenatal care. This has allowed for earlier identification of potential complications for both mothers and newborns, contributing to safer, more timely and effective care.

It is necessary to train staff in the skills required to execute any intervention. High-tech simulations can improve performance of clinicians and staff. ³⁴ However, Bellandi points out that both technical and non-technical skills, such as those necessary for neonatal resuscitation, can also be implemented in low-resource settings though use of low-cost simulators and locally adapted equipment.

Large language models (LLMs), often in the form of chatbots, have exploded onto the healthcare scene and are starting to transform care in LMICs. ³⁵ Vignette studies in Pakistan found that clinicians supported by LLMs substantially outperform those without it. ³⁶ In Rwanda, LLMs answered important clinical questions, even in the local language, more accurately than trained local clinicians and were over 500 times cheaper. ³⁷ Although there are known gaps in the performance of LLMs, they are improving rapidly and are likely to enhance diagnostic safety and quality in LMICs. ³⁸

Implementation of solutions

When introducing new interventions into a new setting, it is important to remember the crucial role of implementation. Dr Buckle reminds us that successful implementation requires multiple elements. Before actual deployment of the intervention, one should first confer with key stakeholders and end users, including patients, about their needs and perceptions of the new initiative. It is crucial to run simulation tests, taking note of barriers and facilitators, and the training needs of staff who will be involved. If possible, it is important to identify who the intervention does and does not work for. Also, one should establish ahead of time what will happen if the intervention breaks down or does not work and identify circumstances when it should not be used. After the intervention is introduced in the practice, it should be reviewed on a regular basis and adapted where necessary. To determine if it is improving care, it is important to evaluate the impact on system performance and patient outcomes. The successes and challenges should be shared with others, locally and beyond. For example, in this issue, a study by Mlouki and colleagues describes a gap between health care workers’ knowledge of waste management guidance and their practice in a Tunisian hospital. ³⁹

In summary, there has been a gratifying proliferation of solutions to improve patient safety, many of which employ advanced technology. This includes the increasing contribution of “smart” solutions based on artificial intelligence and machine learning. High-tech solutions clearly have their place. However, the cost of many of these solutions puts them out of reach for LMICs, as well as lower resourced institutions in high-income countries. There will always be limitations on national and local budgets for healthcare, and it is worth recognizing the power of simple, low-tech solutions. They are scalable and could be used broadly by hospitals of any size, and other types of organizations. They are inexpensive and do not require significant capital investment. They are simple in form, so do not require extensive resources for training. In addition, they tend to be human centered, requiring interaction among people to be effective. This ultimately helps to improve teamwork and coordinated care. Smart institutions around the world should consider low-tech solutions as they work to ensure the safety of their patients.