Keeping patients safe within healthcare is a challenge for all countries, cultures and settings, whether it be a GP practice, hospital ward or community pharmacy.
It is estimated that around one in ten patients are harmed while receiving care. The most frequent types of errors are linked to patients’ medication at the point of prescribing, dispensing or administration. As well as causing harm, errors have economic consequences that can result in longer stays in hospital, more days off work, more GP appointments and further treatment. It is estimated that across the world the cost associated with medication errors is over $40bn year on year. While many studies have researched aspects of medication safety and medication errors, it’s undeniable that the patient safety challenge remains in full force.
Harm reduction as a global goal
In response to the challenge of improving patient safety and reducing harm, the World Health Organization (WHO) published Medication Without Harm, WHO Global Patient Safety Challenge. The 2017 document calls for all countries, cultures and settings to act to reduce harm caused by unsafe medication practices and medication errors.
The goal that the WHO’s document set is to ‘gain worldwide commitment and action to reduce severe, avoidable medication-related harm by 50% in the next five years’. When errors do happen, it is vital that these are reported widely within the healthcare organisation so that lessons can be learnt and that the errors do not recur. Many studies across the globe have, however, shown that few errors are reported and so the necessary learning from this feedback loop is lost.
International research collaboration
In this article, we describe a programme of research conducted within the State of Qatar. The study set out to understand the causes of medication errors and how these could be reduced. We wanted to understand the reporting and non-reporting of errors. We wanted to understand these issues from the perspectives of the healthcare workers (the doctors, nurses and pharmacists) as well as those in positions of leadership with responsibility for making decisions at the very highest level. We hoped that the findings would help to design changes to healthcare practices which, in turn, would reduce errors, improve reporting and, therefore, improve patient safety and reduce harm in patient care.
We have, for many years, worked with Dr Moza Al Hail, the executive director of pharmacy, and her colleagues within the health service in Qatar. For this research, we also involved colleagues from Qatar University, the University of Aberdeen and the Royal College of Surgeons in Ireland. We started the research in January 2015 and completed it in July 2017.
Engaging those who can make a difference
There were three interlinked parts to the research: a survey of all staff, focus groups with both multiple and single discipline staff groups, followed by interviews with key stakeholders.
In the first part, we studied all healthcare workers and their perspectives on why errors occurred and why they were – or were not – reported. We were particularly interested in their views of the safety culture of their organisation. So we focused on their values, attitudes, skills and intentions around medication-related patient safety, as well as those of their colleagues and their organisation. Through posters, emails and lunchtime seminars, we invited all healthcare staff in Qatar to anonymously complete a questionnaire, either paper-based or online, with the option to take part in a follow-on focus group. Respondents shared that there were major issues around how staff were impacted emotionally by how they were treated, or perceived they would be treated by their managers and co-workers, if they made or reported an error. Many felt that they would be punished if they made or reported any error, no matter how small, and that it could affect their livelihood. If they did not report medication errors, we wanted to know the reasons for not reporting them. Very few would report their own or colleagues’ medication errors, and those that did would not report every medication error. The main reasons were due to fear and being worried about the impact of reporting. Also, there were issues about what happened when a report was submitted. Many of those who had submitted reports to their organisation never heard anything and no changes were perceived to happen. This made it less likely that a future report would be submitted. More importantly, there were great concerns of an investigation taking place after submitting a report. There were anxieties about how reporting could affect their reputations and career prospects. They also felt that there were staff shortages at times such as evenings and weekends. Many thought that communication could be more open and processes more transparent at all levels of the organisation and that sometimes supervisors expected too much. All of these circumstances have been reported in other countries and cultures and are known to have potential to lead to medication errors and causing harm to patients.
In the second part, those who indicated at the end of the survey that they were willing to take part in a follow-on focus group met and spoke openly in both single and multi-professional groups. They were asked to focus on real-life medication-related harm scenarios presented to them, how these were handled and what they would have done in similar circumstances. Focus group discussions confirmed the findings from the survey around error reporting processes, trust and communication, and openness and transparency.
In the final part of the study, we were interested in the views and experiences of key people in Qatar including health policymakers, professional leaders and managers, and lead educators and trainers. We were interested in their thoughts on the combined results from the survey and focus group discussions. We also asked about how they thought that medication safety and error reporting could be improved. We interviewed those working as leaders in medicine, nursing, pharmacy and patient safety within the health service. We also interviewed key individuals working at government level in the Ministry of Public Health as well as lead educators of doctors and pharmacists at Qatar University. We felt that these were the potential change-makers or champions who could lead the direction of healthcare policy and practice in Qatar. We found that those interviewed were highly committed to promoting patient safety. They were aware that a lot needed to be done, especially concerning the need to promote trust within the organisation. There was a desire to make workers feel that they would not always be blamed for their unintentional errors. They also felt that more could be done so that all workers felt they had an equal voice to challenge where they saw the need for change in order to promote patient safety and reduce potential harm. There was a need for more open and better communication at all levels. They did, however, describe some areas of very good practice and that there was an opportunity to extend these across the organisation. They were also aware that medication error reporting was not working as well as it could. There was acknowledgement that making these changes was not easy and that all health organisations across the world were challenged by making patient care completely safe and without harm.
So, what difference can this study make? First of all, it is one of the first studies that has researched the perspectives of healthcare workers and those in positions of power in Qatar. We now have scientific evidence of causes of medication errors and why they are not always reported. We also have an indication of commitment from those in positions of power that change needs to be made. With the findings of the three parts of the study, we are now able to propose specific improvements. We will involve groups of health workers and leaders in designing and monitoring these changes. Ultimately, we need to research if these changes make any difference to patient safety and reduction of harm, ultimately working towards the WHO global challenge of 50% reduction in errors.