Improving Patient Safety for better Quality of Care · 1 10 May 2014 An Evidence Brief for Policy...

1

10 May 2014

An Evidence Brief for Policy

Improving Patient

Safety for better

Quality of Care

This evidence brief was prepared to inform dialogue about

multiple policy options. It does not include

recommendations.

This evidence brief was prepared by the Uganda country node of the Regional East African Community Health (REACH) Policy Initiative

Who is this

evidence brief

for? Policymakers, their support staff, and other stakeholders with an interest in the problem addressed by this evidence brief

Why was it

prepared? To inform deliberations about health policies and programmes by summarizing the best available evidence about the problem and viable solutions

What is an

evidence brief

for policy? Evidence briefs for policy bring together global research evidence (from systematic reviews*) and local evidence to inform deliberations about health policies and programmes

*Systematic Review: A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from this research

Share evidence Send this policy brief to people in your network who might find it relevant

2

Authors Harriet Nabudere, MBChB, MPH☼ Delius Asiimwe, BA, MA☼ Daniel Semakula, MBChB, MPH☼ On behalf of the REACH Uganda Patient Safety Working Group§ ☼Regional East African Community Health (REACH) Policy Initiative, Uganda and Supporting the Use of Research Evidence (SURE) for policy in African Health Systems Project, College of Health Sciences, Makerere University, Kampala, Uganda §Members of the working group in addition to the named authors include: Dr Tonny Tumwesigye, Ms Monicah Luwedde, Dr James Mwesigwa and Dr Henry Mwebesa.

Address for correspondence Dr Harriet Nabudere SURE Project Coordinator College of Health Sciences, Makerere University P.O. Box 7072, Kampala Kampala, Uganda Email: [email protected] Contributions of authors HN and Alison Kinengyere developed the search strategy, undertook the search and summarized the search findings. HN and DA reviewed and appraised the literature. HN, DA and DS drafted the report. HN, DA revised the report. Competing interests None known.

Acknowledgements This evidence brief was prepared with support from the “Supporting the use of research evidence (SURE) for policy in African health systems project. SURE is funded by the European Commission’s Seventh Framework Programme (Grant agreement number 222881). The funder did not have a role in drafting, revising or approving the content of the policy brief. We would like to thank the following people for providing us with input and feedback: Tonny Tumwesigye, Monicah Luwedde, James Mwesigwa and Henry Mwebesa. The following people provided helpful comments on an earlier version of the policy brief: Andy Oxman, Jean-Bosco Ndihokubwayo, Shamsuzzoha Babar Syed, Newton Opiyo, Iciar Larizgoitia Jauregui, Nelson Sewankambo and Robert Basaza. Suggested citation Nabudere H, Asiimwe D, Semakula D. Improving patient safety for better quality of care. (SURE policy brief). Kampala, Uganda: College of Health Sciences, Makerere University, 2014 www.evipnet.org/sure

SURE – Supporting the Use of Research Evidence (SURE) for Policy in African Health Systems – is a collaborative project that builds on and supports the Evidence-Informed Policy Network (EVIPNet) in Africa and the Regional East African Community Health (REACH) Policy Initiative. SURE is funded by the European Commission’s 7th Framework Programme. www.evipnet.org/sure

The Regional East African Community Health (REACH) Policy Initiative links health researchers with policymakers and other vital research users. It supports, stimulates and harmonizes evidence-informed policymaking processes in East Africa. There are designated Country Nodes within each of the five EAC Partner States. The REACH Country Node in Uganda is hosted by the Uganda National Health Research Organisation (UNHRO). www.eac.int/health

The Evidence-Informed Policy Network (EVIPNet) promotes the use of health research in policymaking. Focusing on low and middle-income countries, EVIPNet promotes partnerships at the country level between policymakers, researchers and civil society in order to facilitate policy development and implementation through the use of the best scientific evidence available. www.evipnet.org

mailto:[email protected]

http://www.evipnet.org/sure


http://www.eac.int/health

http://www.evipnet.org/

3

Table of Contents

PREFACE 4

ONE-PAGE SUMMARY 7

THE PROBLEM 9

POLICY OPTIONS 18

IMPLEMENTATION CONSIDERATIONS 27

APPENDICES: 31

GLOSSARY, ACRONYMS AND ABBREVIATIONS: 34

REFERENCES 36

See Executive summary

The evidence presented in this Full Report is summarized in an Executive Summary.

4

Preface

The purpose of this report

This report was prepared to inform deliberations of those engaged in developing policies for

patient safety and quality of care, as well as other stakeholders with an interest in these policy

decisions. It summarises the best available evidence regarding the design and

implementation of policies on patient safety.

It is not intended to prescribe or proscribe specific options or implementation strategies.

Rather, its purpose is to allow stakeholders to systematically and transparently consider the

available evidence about the likely impacts of different options for improving safety in

healthcare.

How this report is structured

The report is presented in two parts. The first is an executive summary that summarises each

section of the brief in consideration of the target audience that may not have time to read the

full text of the brief. The second part is a full report which provides details of the problem,

available evidence used to address the problem and approaches used in preparation of the

brief. The full report contains a one page summary of key messages.

How this report was prepared

This report brings together both global and local evidence to inform deliberations about

safety in healthcare. We searched for relevant evidence describing the problem, the impacts

of options for addressing the problem, barriers to implementing those options, and

implementation strategies to address those barriers. The search for evidence focused on

relevant systematic reviews regarding the effects of policy options and implementation

strategies. We have included information from other relevant studies where systematic

reviews were not available or were insufficient. Other documents such as government reports

and unpublished literature were also used. (The methods used to prepare this brief are

detailed in Appendix 4.)

Why we have focused on systematic reviews

Systematic reviews of research evidence constitute a more appropriate source of research

evidence for decision-making than the latest or most heavily publicized research study.(1, 2)

By systematic reviews, we mean reviews of the research literature with an explicit question,

an explicit description of the search strategy, an explicit statement about what types of

research studies were included and excluded, a critical examination of the quality of the

studies included in the review, and a critical and transparent process for interpreting the

findings of the studies included in the review.

Systematic reviews have several advantages.(1) Firstly, they reduce the risk of bias in

selecting and interpreting the results of studies. Secondly, they reduce the risk of being

misled by the play of chance in identifying studies for inclusion or the risk of focusing on a

limited subset of relevant evidence. Thirdly, systematic reviews provide a critical appraisal of

the available research and place individual studies or subgroups of studies in the context of

all of the relevant evidence. Finally, they allow others to appraise critically the judgements

made in selecting studies and the collection, analysis and interpretation of the results.

5

Uncertainty does not imply indecisiveness or inaction

Some of the systematic reviews included in this brief may conclude that there is “insufficient

evidence”. Uncertainty about the potential impacts of policy decisions does not mean that

decisions and actions can or should not be taken. However, it does suggest the need for

carefully planned monitoring and evaluation when policies are implemented.(3)

Limitations of this report

This report is based largely on existing systematic reviews. For options where we did not find

an up-to-date systematic review, we have attempted to fill in these gaps using evidence from

other documents, through focused searches, personal contact with experts, and external

review of the report.

Summarising evidence requires judgements about what evidence to include, the quality of the

evidence, how to interpret it and how to report it. While we have attempted to be transparent

about these judgements, this brief inevitably includes judgements made by review authors

and judgements made by ourselves.

7

One-page summary

The problem

Adverse events in national healthcare

Adverse events can occur from nearly any patient interaction with the healthcare system.

Estimates for adverse drug events (ADEs) stand at 5% to 20% for hospitalized patients while

3% to 14% of hospital admissions are related to ADEs. Errors involving medical devices such

as hypodermic needles, syringes, unsafe blood and blood products are significantly

associated infections including, HIV, Hepatitis B and malaria. Hospital acquired infections

affect up to 28% of admitted patients. The organisational safety culture in health facilities

and hospitals is rather weak with predominantly punitive responses to medical incidents.

Policy options:

1) Nurse staffing models for health facilities

2) Empowerment of health consumers

3) Medication review in health facilities

1. Some nurse staffing models probably reduce death in hospitalized patients, reduce length

of stay in hospital, but could slightly increase readmission rates.

2. There is low to moderate quality evidence supporting benefits for consumer involvement

in developing healthcare policy and research, clinical practice guidelines and patient

information material.

3. Medication reviews can minimize on inappropriate prescribing, associated with adverse

drug events, drug interactions and poor drug adherence which may decrease hospital

emergencies, and slightly decrease mortality.

o Given the limitations of the currently available evidence, rigorous evaluation and

monitoring of resource use and activities is needed for all the options.

Implementation strategies:

A combination of strategies is needed to effectively implement the

proposed options

o Community sensitization and mobilisation to improve knowledge, skills, attitudes, and

motivation of health consumers, and other stakeholders

o Training of allied health professionals to perform drug re-assessments at lower level

health facilities where there are no allocations for clinical pharmacists’ positions.

o Continuing professional education, outreach visits, audit and feedback to motivate

physician prescribers’ in adopting medication review.

o Adequate remuneration, material and non-material incentives are to motivate health

workers, particularly for hard-to-reach areas.

o The current tax-based financing could be expanded with social health insurance and

voluntary schemes such as community/cooperative-based health insurance and private-

for-profit health insurance covering particular populations to scale up the proposed

policy options.

9

The problem

Introduction

In 2009, the Uganda Ministry of Health together with the Private-Not-for-Profit sector and

the World Health Organisation initiated efforts to strengthen patient safety particularly in

rural-based hospitals through research and training.(4)

This prompted for stronger movement towards a national patient safety policy and protective

legislation for health workers reporting medical incidents; to augment the already existing

'Health Sector Quality Improvement Framework and Strategic Plan’.(5, 6) The Ministry and

national stakeholders have underscored the benefit of describing both local and global

evidence on the issue of patient safety to inform a policy decision.(6) The departments for

Quality Assurance and Clinical Services identified key informants for this sector comprising;

policymakers, researchers, health managers, practitioners and civil society to provide views

and information defining the problem, potential policy solutions and implementation

considerations on the issue. The results from this survey have been used as a guideline for

information retrieval and development of this report.(6)

Background

The modern healthcare system is mandated with curing disease and alleviating disability; but

often at a cost of inflicting avoidable harm.(7) The World Health Organisation (WHO)

confirms that significant numbers of patients are harmed due to their healthcare resulting in

permanent injury, increased length of stay in hospitals or even death.(8)

Healthcare errors have been documented from as early as the 1950’s but the field was largely

neglected until the late twentieth century.(9) Most of the studies come from high-income

countries showing a prevalence of 3% to 16% for hospitalised patients. (7) Seventy percent

(70%) of adverse events result in temporary disability, but fourteen percent (14%) result in

death. (10)

A report (1999) published by the Institute of Medicine; ‘To err is human: building a safer

health system’; is commended with bringing patient safety to the forefront of public policy

debate.(11) Conclusions suggested that the majority of medical errors are not caused by the

negligence of individual workers as such; but mainly through faulty systems and processes

leading people to make mistakes or fail to prevent them.(11) Adverse events may result from

problems in practice, products, procedures or systems. Therefore, patient safety

improvements demand system-wide engagement through performance improvement,

environmental safety and risk management, including infection control, safe use of

medicines, equipment safety, safe clinical practice and safe environment of care.(9)

The World Alliance for Patient Safety defines a patient safety incident as ‘an event or

circumstance that could have resulted, or did result, in unnecessary harm to a patient. A

patient safety incident can be a reportable circumstance, a near miss, a no harm incident or

a harmful incident (adverse event).’(12)

10

The WHO Health System framework identifies patient safety as one of four mediators

together with quality, access and coverage; enabling the six health system building blocks to

achieve the health system outcomes.(13) The twelve key Patient safety action areas as

interfaced with the health care system are described in the table below.(14) (See Table 1)

Table 1: Context of Patient Safety within the WHO Health System Framework

Health System Building Blocks

Patient Safety Action areas

Related Millennium

Development Goals

Service Delivery

Health care-associated infections

MDG 4 – Child mortality MDG 5 –

Maternal health MDG 6 –

Communicable diseases

Safe surgical care MDG 4 – Child mortality MDG 5 –

Maternal health

Medication safety MDG 4 – Child mortality MDG 5 –

Maternal health MDG 6 –

Communicable diseases

Health Workforce

Health worker protection MDG 6 – Communicable diseases

Information

Surveillance and research for

patient safety

All health related MDGs

Medical products, vaccines and

technologies

Health care waste management

Medication safety

MDG6 – Communicable disease s

MDG7 – Environmental

sustainability

Financing

Funding for patient safety All health related MDGs

Leadership / Governance

Health systems services and

patient safety

Develop and implement national

policy for patient safety

Knowledge and learning in patient

safety

Awareness raising for patient

safety

Partnerships for patient safety

All health related MDGs

MDG 8 – Partnership development

11

The International Classification for Patient Safety provides a common framework for related

concepts.(12) The context for an incident is described by patient characteristics, incident

characteristics, contributing factors/hazards, and organisational outcomes. A detailed

terminology is provided in the glossary.

The concepts of detection, mitigating factors, ameliorating actions both influence and

determine the actions taken to reduce risk. (See Appendix 1 and 2)

International Policy Context:

The Fifty-fifth World Health Assembly (2002) passed a resolution urging Member States to

pay the closest possible attention to patient safety and directed the WHO secretariat ‘to

develop global norms and standards; promote framing of evidence-based policies and

mechanisms to recognize excellence in patient safety’.(9)

Shortly afterwards within the same year, a WHO inter-departmental working group on

patient safety was set up to consolidate action in response to the resolution.(15)

The World Health Organisation convened a high-level policy meeting (November, 2003) with

representation from all WHO regions, including the African region, to discuss future

international collaboration on patient safety. At the meeting a proposal was fronted and

unanimously supported for the establishment of a World Alliance for Patient Safety.(16)

The World Alliance for Patient Safety was launched in Washington, DC in 2004, attended by

health policy-makers, representatives’ patients' groups and the World Health Organization to

advance the patient safety goal of "First do no harm", and reduce the adverse health and

social consequences of unsafe health care.(17)

The WHO African Region, Health Systems and Services Cluster/Patient Safety Unit has

developed a guide to support countries in developing national patient safety policies and

strategic plans. (14)

Regional Activities on Quality and Safety:

Two regional meetings of the World Alliance for Patient Safety took place in the African

region (January, 2005). The first meeting in Nairobi, Kenya and the second meeting in

Durban, South Africa included participation from senior government officials,

representatives from government agencies, ministers of health, senior clinicians, health care

managers and representatives from academic and medical educators from countries across

Africa. These two regional meetings aimed to build awareness on the safety of care in African

countries and the commitment of interested countries, current and potential agencies and

many other partners to improve patient safety. (18, 19)

A patients for patient safety workshop was held in Uganda (March, 2011). Patients, family

members and advocates from Ethiopia, Ghana, Kenya, Malawi, Uganda and Zambia, joined

health-care workers and policy-makers to share experiences of harm in health care to work

together to improve health-care safety in their countries. Participants urged Member States

and health-care providers to make patient safety a priority in Africa.(20)

12

National Activities on Quality and Safety:

National stakeholders in particular, the Private-Not-For-Profit (PNFP) sector have been

actively involved in building a safer culture and practices within hospitals over the past few

years.

Kisiizi hospital in South-Western Uganda, supported by the WHO African Partnerships for

Patient Safety (APPS, 2009) collaborated in safety improvement through a pairing process

with the Countess of Chester Hospital (United Kingdom).(4) The hospital now has an

infection control team in place; prepares its own alcohol-based hand rub from the local

banana supply, built two incinerators for waste management and purchased an industrial

washing machine with funding raised by the APPS team in Chester. Hospital infection rates

have fallen and are regularly monitored.(21)

The Uganda Catholic Medical Bureau (2010) instituted quality and safety improvement

initiatives; training for affiliated hospitals and developed supporting guidelines and training

curriculum.(22-24) Pilot testing for two interventions; Voluntary Error Reporting and a

Surgical Safety Checklist were conducted in 5 hospitals (Kisubi, Buluba, Nsambya, Nkozi and

Virika). (22) Serial on-site trainings were held for medical directors, senior nursing officers

and quality assurance committee members from the five hospitals.(22) Follow-up visits to

determine on-site compliance assessment for the incident reporting system and safe surgery

checklist were done the following year, 2011. (23) A Quality and Patient Safety management

guide was developed in 2012, as well as plans for a Hospital Safety Culture Survey for

affiliated units.(24)

The WHO African Regional office organized a regional consultation involving patients, family

members, health advocates, health-care workers and policy-makers in Entebbe, Uganda

(2011). This provided participants the opportunity to share their experiences of harm in

healthcare and passion for change to work together to improve health-care safety in their

countries

A number of national hospitals have also set up Infection Control teams and Units, such as

the National Referral hospital, Mulago; Nsambya, Kibuli, Lacor and Rubaga hospitals.(6)

The Ministry of Health oversees a national quality improvement committee to coordinate

these activities at national level, and has developed extensive guidelines to enhance quality of

healthcare including; National Guidelines of Infection Control; Post-Exposure Prophylaxis

guidelines; Waste Management guidelines; the Patient Charter, the Uganda Clinical

Guidelines, Standards for injection safety and health care waste management practices and

the Health Sector Quality Improvement Framework and Strategic Plan.(25)

During the mid-nineties, the Ministry of Health in collaboration with the United States

Agency for International Development developed a comprehensive quality of care strategy

called the Yellow Star Program. This however, was pilot strategy covering only 30% of the

population (12 out of 45 districts) for the period during the pilot evaluation. (26) The

program included an assessment of facilities based on their physical characteristics, the

availability of equipment and supplies, and the interactions between clients and providers.

The Yellow Star was awarded to those facilities that achieved and maintained 100% of these

standards for a minimum of two consecutive quarters.(26)

13

Private Educational institutions such as Uganda Martyrs University, the International Health

Sciences University, have worked in collaboration with PASIMPIA, Patient Safety

Improvement in Africa, to develop short courses on quality improvement and patient safety,

at Diploma and Masters’ level for the former.(27-29) Makerere University established the

Regional Centre for Quality of Health Care to provide leadership in building capacity to

improve quality of health care by promoting better practices trough networking, strategic

partnerships and education.(30)

Size of the problem

Adverse events can occur from nearly any patient interaction with the healthcare system. The

World Alliance for Patient Safety commissioned a report on the evidence surrounding global

causes and impact of unsafe care.(7) This assessment identified key areas in patient safety at

both clinical and organizational levels.

National data have been used to elaborate this outline highlighting the size and cause of the

problem for Uganda.

Adverse Drug Events or Medication Errors:

Tumwikirize (2011) reports that 5% to 20% of hospitalized patients in developing contexts

suffer from Adverse Drug Events (ADE) and 3% to 14% of hospital admissions are related to

ADEs.(31) A study conducted in Mbarara Regional hospital from Western Uganda found

prevalence of drug-to-drug interactions at 23%, but with most of these not being clinically

significant.(32)

Medical Device Errors:

Errors involving medical devices such as hypodermic needles, syringes or equipment can be

classified as: manufacturer-related, user-related or design-related. (7)

Model-based estimates for Uganda, Cote d’Ivoire and Ghana compared different types of

injection devices for HIV and Hepatitis B transmission between patient-to-patient, patient-

to-health care worker and patient-to-community interfaces. (33) The commonly used

disposable and resterilisable needles and syringes carry a hidden but huge burden of

iatrogenic disease. Ekwueme and colleagues advise procurement of alternative injection

devices associated with minimal risk. (See Table 2 below)

Table 2: Numbers of hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections related to injection devices (per million injections)

Type of Injection

Device

Number of Infections

Patient-to-Patient

transmission

Patient-to-Health

care worker

transmission

Patient-to-

Community

transmission

All Routes totals

HBV HIV HBV HIV HBV HIV HBV HIV Both

Resterilizable N&S

8100 81 1350 14 <1 <1 9450 95 9545

14

Disposable N&S

8100 81 810 8 3 <1 8913 89 9002

Reusable-nozzle jet

injector

270 3 0 0 0 0 270 3 273

Auto-shielding N&S 0 0 0 0 0 0 0 0 0

Disposable-

cartridge jet injector

0 0 0 0 0 0 0 0 0

N&S = Needle and Syringe

Source: Ekwueme et al., 2002 (33)

A Demographic Health Surveillance (DHS) comparative report on the use of medical

injections and associated knowledge/perceptions of HIV risks examined the association

between exposure to medical injections and HIV serostatus for several Sub-Saharan African

countries. (34)

The findings are presented in Table 3 and Table 4 below.

Table 3: Knowledge on HIV risks related to injections and blood transfusions

Country/Year Women (15-49 years) Men (15-49 years)

Knows to avoid HIV infection by avoiding:

Injections Blood

Transfusions

Injections Blood

Transfusions

Uganda (2004/2005) 8.2% 2.6% 9.3% 5.5%

Kenya (2003) 5.2% 5.0% 4.8% 6.8%

Tanzania (2003/2004) 11.1% 4.6% 14.1% 5.5%

Source: DHS/AIS 2003-2006

Table 4: HIV Prevalence by Receipt of more than 3 Medical Injections in Recent Past


Yes No p-value Yes No p-value

Uganda (2004/2005) 10.2% 6.1% 0.000 8.5% 3.9% 0.000

Ethiopia (2005) 3.2% 1.6% 0.004 1.4% 0.9% 0.247

Zimbabwe (2006) 33.9% 20.8% 0.000 36.0% 14.1% 0.000


Unsafe blood products and Blood transfusion:

Unsafe blood products are a potential mechanism for HIV exposure, and other blood-borne

infections such as Hepatitis B, Syphilis and Malaria. Upto 5% to 15% of HIV infections in

developing countries result from unsafe blood transfusions.(35)

Having ever received a blood transfusion is significantly and positively associated with being

HIV-positive among women, but not among men.(34) (See Table 5)

15

This is because women of child-bearing age are potentially prone to severe bleeding or

haemorrhage, which is clinically managed by blood transfusion.

Table 5: HIV Prevalence by Ever received a Blood Transfusion


Yes No p-value Yes No p-value

Uganda (2004/2005) 10.2% 6.1% 0.000 8.5% 3.9% 0.000

Ethiopia (2005) 3.2% 1.6% 0.004 1.4% 0.9% 0.247

Zimbabwe (2006) 33.9% 20.8% 0.000 36.0% 14.1% 0.000


Hospital Acquired Infections:

A nosocomial infection is one which is acquired during a patient’s stay in hospital; hence a

hospital acquired infection (HAI). A survey conducted by Lacor hospital in Northern Uganda

found an overall HAI prevalence of 28% among admitted patients.(36) Surgery contributes

the highest proportion at 47% and pediatric patients (children) are lowest at 21%. Blood

stream infections were the most frequent, followed by surgical wound infections, urinary

tract infections, lower respiratory tract and gastrointestinal infections. HAI prevalence was

associated with increased length of stay in hospital, use of intravenous cannulas, urinary

catheters and emergency surgery. Predisposing patient characteristics included: severe low

nutrition status, anemia and complications related to the diagnosis at admission.(36)

Cause of the problem

Global experts commissioned by the World Health Organization examined the current state

of the research addressing healthcare safety and categorized this in a framework of

organizational structure, processes and outcomes of unsafe care.(7) This classification is used

here, in part, to elucidate the causes of the problem for Uganda using local data and research.

Organizational factors contributing to Unsafe Care:

a) Inadequate Human Resources for Health Poor staffing levels for qualified health professionals lead to ‘production pressures’; where

the optimal patient care capacity of an individual healthcare provider or system has been

exceeded.

This hinders effective communication amongst health workers, leads to provider fatigue and

creates a less productive environment with more room for error.(7)

There is a health worker shortage in Uganda’s public health sector where 47% of approved

positions in government owned facilities are vacant.(37) This is further exacerbated by the

urban-rural divide where 71% of medical doctors work in the central urban region which is

inhabited by only 27% of the total population. 64% of nurses and midwives are also working

in the central urban region.(38)

b) Provider Fatigue Research from high-income countries shows that doctors-in-training working more than

24hr shifts make 36% more serious errors compared to doctors-in-training doing non-

16

extended shifts.(39) Intern doctors report making four times as many fatigue-related errors

leading to a patient’s death and suffer occupational injuries themselves, such as increased

risk for motor vehicle accidents.(40)

c) Organisational Safety Culture A positive workplace culture may result in improved safety practices. The Uganda Catholic

Medical Bureau conducted an organizational safety survey for 27 hospitals within their

network (2012). Findings reveal there is under-reporting for incident errors (65%), with a

highly punitive organizational culture discouraging openness and communication. Teamwork

within and across wards was very high, including fairly good management support with

overall perceptions of patient safety at 53%.(41)

A survey of health professionals in Masaka Regional hospital classified medical errors as:

diagnostic (67.9%), surgical (21.3%), preventive (5.3%) and medication errors (5%). Among

the medication errors, polypharmacy (60.9%) ranked highest, in the diagnostic errors while

omitted diagnosis was high at 78.7%. The respondents suggested instituting a formal error

reporting system, increasing the staff level, strengthening of training, dissemination of

standard operating procedures and support supervision among others.(42) A study at the

Mulago national referral hospital revealed that sinks on the wards were not readily available

and soap was uncommon at the sinks of the medicine and obstetrics wards but more

commonly available in the surgery wards. Alcohol gel was rarely available.(43)

Notably, a number of national hospitals have set up Infection Control teams and Units, such

as the National Referral hospital, Mulago; Nsambya, Kibuli, Lacor, and Rubaga hospitals.(6)

Additional research from developed settings addresses design issues of medical devices,

architecture and procedures to maximize efficient human use and minimize on adverse

incidents.(7)

d) Poor referral systems Health workers in private practice are influenced mainly, by commercial disincentives for

referring, leading to under-referral and late referrals. On the other hand, health workers in

public units have incentives to over-refer. Patients often do not complete referrals due to lack

of money, transportation problems, and responsibilities at home.(44, 45)

e) Discharge Planning A patient’s discharge from hospital may be delayed for both medical and non-medical

reasons. Non-medical causes account for approximately 30% of delays and usually occur due

to poor knowledge about a patient’s social circumstances, deficient logistical organisation,

and inadequate communication between hospitals and community service providers.(46)

Discharge planning helps rectify avoidable problems by developing individualized plans for

patients prior to their departure from a hospital. Such plans typically include a pre-admission

assessment, case findings on admission, individual inpatient assessment, and discharge

preparation and implementation. The discharge planning process must be monitored and

documented.(47)

Processes Underlying Unsafe Care:

a) Clinical Misdiagnosis Misdiagnosing patients’ illnesses leads to health care mismanagement, with exposure to

unnecessary procedures, drugs, while at the same time not dealing with the actual problems

17

they are suffering from. Nankabirwa and colleagues (2009) found that the recommended

‘presumptive’ diagnostic practices for malaria result in massive over-diagnosis across all age

groups and transmission areas in Uganda.(48) Paradoxically, under-diagnosis is also

common in children <5 years in up to 39.9% of cases.

To address this gap, the researchers’ advocate for a shift from presumptive to parasitological

diagnosis with scaling-up of malaria rapid diagnostic tests and strengthening of malaria

microscopy.(48)

b) Counterfeit and Sub-standard drugs The WHO defines sub-standard medicines as ‘products whose composition and ingredients

do not meet the correct scientific specifications and which are consequently ineffective and

often dangerous to the patient.’ (49)

These may occur as a result of negligence, human error, insufficient human and financial

resources or counterfeiting.

Sub-standard medicines account for 10% of the global market and up to 25% of medicines

consumed in developing countries.(49) Repeated exposure leads to treatment failures, drugs

resistance and death.

Nayyar and colleagues (2012) reviewed 21 surveys of anti-malarial drugs from six classes for

21 countries from sub-Saharan Africa including Uganda and found that 35% failed chemical

analysis, 36% failed packaging analysis, and 20% were classified as falsified. In some cases

obtaining a genuine package sample for comparison was difficult, therefore, where packaging

analysis was not possible, researchers assumed that a drug containing no active

pharmaceutical ingredient, or an unstated drug or substance, was falsified.(50)

In March 2013, the Ministerial Cabinet passed the Uganda Anti-Counterfeit Bill 2010.(51)

The Bill, which is now before the parliamentary committee on trade, prohibits manufacture,

trade and release of counterfeit products into the channels of commerce. This will

complement the initiative by the Uganda National Bureau of Standards’ Pre-Export

Verification of Conformity (PVoC) programme to ensure quality of products.(51)

18

Policy Options

National stakeholders in patient safety identified potential policy solutions to improve the

quality of Uganda’s health care services.(6) We assessed the research evidence on the

effectiveness of these safety practices, as well as others from the literature, and their

implementation in a developing context, such as Uganda’s.

Therefore, the policy options presented in this section are not entirely exhaustive, but

represent safety interventions that could be feasibly adapted for the local context supported

by high quality research evidence.

Many patient safety practices are complex sociotechnical interventions whose targets may be

entire health care organizations or groups of providers, e.g., nurse staffing ratios, while some

of them focus on clinical events, such as, preventing in-facility pressure ulcers. The

interventions identified here emphasize a multi-targeted health systems perspective.

The three policy options can be adopted independently, or could complement one another.

Patient safety incidents can be reduced through appropriate nurse staffing models,

empowering patients and families to inform healthcare policy and practice, and review of

medication in hospitalized patients.

Policy Option 1:

Nurse Staffing Models for Health Facilities

Nurse staffing model interventions include changes to nurse staffing levels, the nursing skill

mix, the educational preparation of nurses, staff allocation models, shift patterns, and the use

of overtime and agency staff.(52)

Nursing resources allocated to meet patient care needs can be quantified in terms of numbers

of patients in the health unit; i.e., nurse per patient ratio. Nursing skill mix refers to the

proportion of different nursing grades, and levels of qualification, expertise and

experience.(53)

Current Status of Nurse Staffing Models for Health Facilities

The Uganda Nurses and Midwives Council is responsible for setting and regulating training

standards and has registered at least seventy nurse training institutions in the country.

Almost twenty (20%) percent are government-owned, with the majority being faith-based or

private-not-for-profit (42%) and private-for-profit at thirty-eight (38%) percent.(54) The

nurse training curricula feature a mix of certificate, diploma and degree (Bachelors and

Masters) for general nursing and specialist nursing including; enrolled and registered

midwives, psychiatric nursing (Butabika School of Mental Health Nursing), public health

nursing (Public health nurses’ College), nutritionists, palliative care nursing, paediatric

nursing (Jinja School of Nursing and Midwifery) and others.(54)

A human resources for health audit showed public sector health facilities staffing at 60.5%

nationally, with unfilled vacancies at 39.5%.(55) There are 64% of nurses and midwives

serving the central urban region which covers only 27% of the population.(38) Specialist

nursing posts in public health, psychiatry and nutritionists at the national referral hospitals

19

record 17% vacancies, while at the eleven regional referral hospitals this comes to 24%. There

is an exponential increase of the specialist nursing gap at 42% for seven general hospitals,

with poorer recruitment patterns at the lower level health facilities.(56)

Inadequate staffing and retention are influenced by insufficient training capacity,

unattractive remuneration, poor living conditions with inadequate housing and lack of social

amenities, particularly in rural areas.(37)

Effectiveness of hospital nurse staffing models

Butler and colleagues (2011) conducted a high quality systematic review assessing hospital

nurse staffing models.(52) The reviewers assert that some nurse staffing models probably;

(See Table 6 and Table 7)

Reduce death in hospitalized patients

Reduce length of stay in hospital

Slightly increase readmission rates

Table 6: Adding dietary assistants to usual nurse staffing:

Patients or population: Patients in hospital

Settings: Netherlands, United Kingdom, and United States

Intervention: Adding dietary assistants to usual nurse staffing

Comparison: Usual nurse staffing

Outcomes Impact Number Quality

of of the

Participants

(studies)

evidence

With usual

nurse staffing

Adding dietary

assistants to

nurse staffing

Relative change (GRADE)*

Deaths in

trauma unit

102 per 1000 42 per 1000

(16 to 103)

59% relative

decrease

302

(1)

⊕⊕⊕

Moderate

Deaths in

hospital

146 per 1000 82 per 1000

(42 to 160)

44% relative

decrease

302

(1)

⊕⊕⊕

Moderate

Deaths at 4

months

229 per 1000 131 per 1000

(78 to 218)

43% relative

decrease

302

(1)

⊕⊕⊕

Moderate

*GRADE Working Group grades of evidence

High: We are confident that the true effect lies close to what was found in the research.

Moderate: The true effect is likely to be close to what was found, but there is a possibility that it is substantially

different.

20

Low: The true effect may be substantially different from what was found.

Very low: We are very uncertain about the effect.

Overall Assessment: This is a high quality systematic review with only minor limitations.

Table 7: Addition of a specialist nursing post to usual staffing:

Patients or population: Patients in hospital

Settings: Netherlands, United Kingdom, and United States

Intervention: Addition of a specialist nursing post(s) to usual staffing

Comparison: Usual nurse staffing


of of the

Participants

(studies)

evidence

With usual

nurse staffing

Addition of

specialist

nursing post to

usual staffing


Length of stay

1.35 lower

(1.92 to 0.78

lower)

235

(2)

⊕⊕⊕

Moderate

Readmission

174 per 1000 200 per 1000

(153 to 265)

15% relative

increase

878

(3)

⊕⊕⊕

Moderate




different.




Relevance of the research findings to the Ugandan context:

Applicability

There has been a strong national tradition of training general and specialist nurses, both by

government, but more particularly by the private sectors.(54)

The major problem is staff attraction and retention in facilities owned by the non-profit

sector.(57) Motivational factors such as adequate financial incentives, career development

and management issues particularly health worker recognition, adequate resources and

appropriate infrastructure can improve morale significantly.(58)

21

Equity considerations

This intervention focuses on nurse staffing models at hospitals, and as such is influenced by

health care seeking behavior of the public at these facilities. The recent national household

survey by the Uganda Bureau of Statistics (2012/2013) shows facilities first visited during

illness with private clinics/hospitals at thirty-seven percent (37%); government health

centres at thirty-five percent (35%); and government hospitals at seven percent (7%), among

others.(59) Private facilities would be associated with higher out-of-pocket expenditures for

healthcare and thus increase inequity for poorer socio-economic, and rural population

groups. Also less attendance at hospitals versus health centres would further marginalize

most of the population. Hence the need for a national investigation of successful hospital

nurse staffing models at lower level health centres II, III and IV.

Scaling up considerations and research gaps

Scaling up of this policy intervention in the national context requires rigorous monitoring of

related inputs, processes, and evaluation of the impact and cost-effectiveness of various nurse

staffing structures on patient-important outcomes. Limitations from the evidence suggest the

need for wider research on nurse staffing interventions in relation to educational levels, skill

mix, preferably from larger experimental studies drawing from primary local data.

Policy Option 2:

Empowerment of Health Consumers

Patient-centeredness is increasingly recognized as an important aspect of health care and

incorporates various approaches to involve patients and their families’ participation in

reduction of adverse events, and promotion of consumer rights.(60)

The World Health Organization’s Declaration of Alma Ata enshrines the rights and duties of

communities to participate in the planning and implementation of their healthcare.(61)

Health consumers can be involved in developing healthcare policy and research, clinical

practice guidelines and patient information material, through consultations to elicit their

views or through collaborative processes. Consultations can be single events, or repeated

events, large or small scale.(62)

Current Status of Empowerment of Health Consumers

Uganda’s civil society is active in promoting health rights and health voices for the public. An

NGO (non-governmental organizations) study in the health sector found that indigenous

NGOs are largely characterized by mainly urban and localized membership, high financial

dependence on foreign organizations, with little or no funding from the Government, limited

human resource skills, poor sustainability and emphasis on service delivery roles versus

advocacy work.(63)

Some successful efforts at collaborating with local communities for health include training

community members for health promotion activities, e.g. constructing pit latrines, hand-

washing facilities and protection of natural springs for safe water.(64)

National stakeholders have been involved in influencing decision-making through policy

dialogues, constituted working groups in developing policy briefs, collaborated through

advisory groups in setting health priorities and developing a national repository for health

systems evidence.(65)

22

Surveys by the Uganda National Health Consumers Organization’s indicate weak client

feedback mechanisms on services, and poor knowledge of patients’ rights by both health

consumers and providers.(66-68) The Uganda government has instituted a Patients’ Charter

to promote awareness about patients’ rights and responsibilities and support consumer

demand for good quality health care.(69)

Effectiveness of Consumer Involvement in developing healthcare policy and

practice

Nilsen and colleagues (2006) conducted a high quality systematic review assessing methods

of consumer involvement in developing healthcare policy and research, clinical practice

guidelines and patient information material.(62)

There was little evidence from randomized controlled trials (RCTs) of the effects of consumer

involvement in healthcare decisions at the population level, but concluded that RCTs are

feasible for providing evidence about the effects of involving consumers in these decisions.

Consumer involvement in health policy

One study from the review compared two forms of deliberative consumer involvement

(telephone discussion and a group face-to-face meeting) and a mailed survey in eliciting

priorities for community health goals. Very low quality evidence suggests that both telephone

discussions and face-to-face meetings achieve more involvement than a mailed survey, based

on the low response rate to the mailed survey.

Consumer involvement in health research

There is moderate quality evidence from two studies that;

There may be little or no difference in worries or anxiety associated with procedures for

patients receiving information material developed following consumer consultation,

compared with patients receiving material developed without consumer consultation.

Consumer consultation prior to developing patient information material probably

results in material that is more relevant, readable and understandable to patients.

Moderate quality evidence from one study shows that consumer consultation before

developing patient information material can probably improve the knowledge of patients who

read the material.

Consumer involvement in preparing patient information

There is low quality evidence from one study that consumer consultation in the development

of consent documents may have little if any impact on;

Participant’s self-reported understanding of the trial described in the consent document

Satisfaction with study participation

Adherence to the protocol

Refusal to participate

None of the studies from the review addressed harmful effects of consumer involvement,

such as tokenism or consumer involvement slowing the process down and making it costlier.

23


Applicability and Equity considerations

Current efforts for consumer involvement in national healthcare are commendable and

should be expanded to incorporate complementary perspectives from the public and improve

implementation of research findings; resulting in better care and health for all. Consumer

participation can be viewed as a goal in itself by encouraging participative democracy, public

accountability and transparency.

This option has considerable potential to improve equity as long as representation of

marginalized demographic groups such as; women, the elderly, children, the poor, and

others, are emphasized.

Research gaps

There is uncertainty regarding the impact and cost-effectiveness of consumer involvement in

healthcare particularly; methods for recruiting consumers, degree of involvement, forums for

communication, degrees of consumer involvement in decision-making, ways of providing

training and support, and others. These interventions need to be evaluated in well-designed,

randomized trials where possible.

Policy Option 3:

Medication review in health facilities

Medication review is the systematic re-assessment and possible change of an individual

patient’s prescriptions in order to optimize on the effectiveness of therapy and to minimize

drug harms. Medication reviews can be performed by a clinical pharmacist, physician or

other healthcare professional in a facility to minimize on inappropriate pharmacotherapy or

prescribing, which are associated with adverse drug events, drug interactions and poor drug

adherence. (70)

Current Status of medication review in health facilities

The Uganda Health Service Commission mandated, in part, to review qualifications and

terms of service for health professionals, requires Clinical Pharmacists at all levels to provide

‘advice to clinicians and other health professionals on prescriptions given’ in addition to

other regular duties.(71) A human resources for health audit showed vacancies at 22% for

clinical pharmacists at the national referral hospitals of New Mulago and Butabika. The

deficit increased sharply to 71% unfilled posts at seven regional referral hospitals, and this

was further exacerbated at some general district hospitals with the only single post not being

filled.(56) There are no pharmacists indicated at health centres II, III and IV.

24

Effectiveness of medication review in hospitalised patients

Christensen and Lundh (2013) conducted a high quality systematic review investigating

review of medications in hospitalised patients to reduce morbidity and mortality.(70) The

findings suggest that medication review by pharmacists or physicians may influence the

outcomes below at one year of follow-up:

(See Table 8)

May decrease hospital emergencies

May slightly decrease mortality

May lead to little or no difference in hospital readmissions

Table 8: Medication Review in Hospitalised Patients

Patients or population: Adult patients in hospital

Settings: Ireland, Sweden, Denmark, and United States of America

Intervention: Medication review compared with standard care for hospitalised adult patients

Comparison: Standard care


of of the

Participants

(studies)

evidence

With standard

care

Medication

review


Hospital

Emergency

Department

contacts

(all-cause)

1 year

Low Risk Population

574

(3 studies)

⊕⊕⊕

Moderate

100 per 1000 64 per 1000

(46 to 89)

36% relative

decrease

High Risk Population

300 per 1000 192 per 1000

(138 to 267)

36% relative

decrease

Mortality (all-

cause)

1 year

Low Risk Population

1002

(4)

⊕⊕

Low

200 per 1000 196 per 1000

(156 to 246)

2% relative

decrease


400 per 1000 392 per 1000

(312 to 492)

2% relative

decrease

Low Risk Population

25

Hospital

readmission

(all-cause)

1 year

300 per 1000 303 per 1000

(264 to 348)

1% relative

increase

956

(4 studies)

⊕⊕

Low


600 per 1000 606 per 1000

(528 to 696)

1% relative

increase




different.





Applicability and Equity considerations

The majority of medication reviewers from the research studies were clinical pharmacists and

physicians. National health staff allocation does not provide for pharmacists at health centres

II, III, and IV. Doctors are allocated at health centres IV and above. Noting that there is less

attendance at hospitals versus health centres would further marginalize many patients.

Training of other allied health professionals to perform the needed prescription re-

assessments would be required for the lower level units.

Scaling up Considerations and Research Gaps

This intervention should be scaled up in the context of rigorous monitoring for related costs,

cost-effectiveness, and evaluations of other cadres of allied health professionals performing

drug re-assessments in facilities.

Potential alternative policy interventions

Potential interventions identified by stakeholders, and from the research, concerned with

safety and quality of healthcare that have not been explicitly discussed either as policy

options or implementation strategies are elaborated on further below, but for many of these

the data was insufficient to advise on policy direction.

These include: Incident or error reporting, Hygiene, Education and training of health

personnel, Safety assessment, Safety enforcement and others.(6)

Incident or Error reporting:

There were no systematic reviews identified on the efficacy of reporting of adverse clinical

events as an effective method of improving the safety of healthcare. However, a systematic

review by Parmelli and colleagues (2012) examines interventions to increase clinical incident

reporting in healthcare, but not to investigate the effectiveness of incident reporting per

se.(72) The investigators concluded that rigorous evidence for these interventions is still

26

lacking due to limitations from studies found, thus it was not possible to draw conclusions for

clinical practice.

Hygiene:

The link between hand hygiene and improvements in healthcare-associated infections has

been hard to prove definitively.(60) Notwithstanding, the World Health Organization (WHO)

recommends hand hygiene practices to reduce health care-acquired infections. (73)

Two reviews; Ejemot-Nwadiaro et al. (2012) and Gould et al. (2010) both focused on

interventions to improve compliance with hand hygiene, rather than on the efficacy of hand

hygiene for reducing healthcare-associated infections.(74, 75) Ejemot-Nwadiaro and

colleagues looked at trials of interventions to increase the use of hand washing in institutions

in high-income countries and in communities in low- or middle-income countries, and found

that many of the interventions like educational programs, leaflets, and discussions were

effective.(75) Gould and colleagues decided there is still not enough evidence to be certain

what strategies improve hand hygiene compliance.(74)

Patient Safety assessment and enforcement:

Flodgren and colleagues review (2011) highlights the lack of high-quality studies to draw any

firm conclusions about the effectiveness of external inspection of compliance with standards

in improving healthcare organisation behaviour, healthcare professional behaviour or patient

outcomes.(76)

Ketelaar and colleagues review (2011) found that the small body of evidence available

provides no consistent evidence that the public release of performance data changes

consumer behaviour or improves care. Evidence that the public release of performance data

may have an impact on the behaviour of healthcare professionals or organisations is

lacking.(77)

27

Implementation Considerations

Reduction of patient safety incidents can be enhanced through the strengthening and

expansion of the already existing interventions of appropriate nurse staffing models,

empowering patients and families in healthcare, and medication reviews.

This may require several changes within the wider health system framework, in terms of

identifying implementation barriers and circumventing these with effective strategies.

Enablers providing a conducive environment for scaling up:

Political support from national and local authorities to improve safety and quality of the national health system

Longstanding government collaboration with the private-not-for-profit sector which controls forty percent of national hospitals

Medication Review is a professional pre-requisite for Clinical Pharmacists under the current national terms of service

Evidence regarding key barriers to improving patient safety and strategies to address them is

summarized in Table 9.

28

Table 9: Barriers to Improving Patient Safety and Proposed Strategies to overcome them:

Recipients of Care

Bar

rier

Knowledge, Skills, Attitudes, and Motivation of Health Consumers, and other Stakeholders The majority of national health consumers are not able to effectively influence health care decisions and services. This is due to low literacy levels, and minimal civil engagement for marginalized groups, resulting in poor attitudes and motivation towards consumer involvement in health care.(63)

Implementation strategies Evidence

Community Sensitization and Mobilisation Extensive sensitization and mobilization of recipients of care for effective ownership of health services and systems.

Consumer Recognition and Awards Recognition and awards to boost consumer confidence and participation.

Learning from successful precedents such as the NHS (UK National Health Service) ‘INVOLVE’ program on degrees of consumer participation in research; consultation, collaboration and control.(78) Recognition and awards for citizen contributions could improve motivation.(79) Sustainability through national institutions, such as the Uganda National Health Research Organization and involving stakeholders in policy dialogues, working groups, advisory groups in setting health priorities for research, policy and participation in decision-making.(65)

Providers of Care

Bar

rier

Knowledge and Skills of Health Workers

There are no clinical pharmacist posts allocated for lower level health centres II, III and IV.(56) Training of other allied health cadres is needed to fill this gap.


Training of allied health professionals to perform drug re-assessments. It is a professional prerequisite for clinical officers to prescribe medications.

Educational meetings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients.(80)

29

Bar

rier

Motivation to change or adopt new behaviour Some trials report that the majority of recommendations (61% to 82%) from drug re-assessments were not followed by prescribing physicians.(70, 81)


Continuing professional education, outreach visits, audit and feedback Educational meetings (training workshops), educational outreach (a personal visit by a trained person to health workers in their own settings), audit and feedback (a summary of performance over a specified period of time given in a written or verbal format) can be used alone or in combination with each other and other interventions to improve health worker practice.

Educational meetings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients. Other interventions include; audit and feedback, and educational outreach visits. Strategies to increase attendance at educational meetings, using mixed interactive and didactic formats, and focusing on outcomes that are likely to be perceived as serious may increase the effectiveness of educational meetings.(80, 82-85)

Health Systems Constraints

Bar

rier

Inadequate Human Resources

An increased supply and distribution of specialist nurses would be needed. Specialist nursing posts in public health, psychiatry and nutritionists at the national referral hospitals record 17% vacancies, while at the eleven regional referral hospitals this comes to 24%. There is an exponential increase of the specialist nursing gap at 42% for seven general hospitals, with poorer recruitment patterns at the lower level health facilities.(45)


Financial and non-financial incentives

Adequate remuneration, material and non-material incentives are essential to motivate health workers.

A systematic review by Willis-Shattuck (2008) examined factors affecting retention of health workers in low income settings. Motivational factors such as adequate financial incentives, career development and management issues particularly health worker recognition, adequate resources and appropriate infrastructure can improve morale significantly.(47) Another systematic review by Penaloza and colleagues (2011) affirms that in addition to financial rewards, career development, continuing education, improving hospital infrastructure, resource availability, better hospital management and improved recognition of health professionals, help reduce on ‘brain-drain’.(86)

30

Bar

rier

Inadequate Financial Resources

Additional financial resources would be required for the newly recruited staff including wages, and other related costs for optimum function of the public health system. Considerable resources would be needed for mobilization, and sensitization of health consumers. In the Abuja Declaration of 2001, African governments pledged to commit at least 15% of their national budgets to the health sector.(87) However, government expenditure on health is 7.6% of the GDP (gross national product).(88)


Health Insurance Schemes A transition towards a universal health care coverage would require a combination of the current tax-based financing plus social health insurance and voluntary schemes such as Community/Cooperative-based health insurance and private-for-profit health insurance covering particular populations. Community-based health insurance (CHIs) schemes are voluntary, private associations using the principle of pooling health risks and resources sometimes refered to as rural health insurance, mutual health organizations or medical aid societies among others.

Social health insurance (SHI) is normally public-managed, mandatory, with subscription by the formal sector. SHI pools both the health risks of its members and the financial contributions of households, businesses and government. A systematic review (2012) by Spaan and colleagues investigating impact of health insurance in Africa and Asia shows protection against the detrimental effects of user fees and a promising avenue towards universal health-care coverage.(89) A high quality review (Ekman, 2004) on CHIs in low-income countries found strong evidence that community-based health insurance provides some financial protection by reducing out-of-pocket spending. There is evidence of moderate strength that such schemes improve cost-recovery. There is weak or no evidence that schemes have an effect on the quality of care or the efficiency with which care is produced.(90)

31

Appendices:

Appendix 1. Detection of Patient Safety Incidents (12)

People

Involved

Healthcare professional

Healthcare worker

Another Patient

Relative

Volunteer

Guardian

Friend/Visitor

Detection Carer/Home Aid Assistant

Interpreter/Translator

Pastoral Care Personnel

Emergency Service Personnel

Process Error Recognition

By Change in Patient’s Status

By

Machine/System/Environmental

Change/Alarm

By a Count/Audit/Review

Proactive Risk Assessment

32

Appendix 2. Mitigation of Patient Safety Incidents (12)

Directed to

Patient

Help Called For

Management/Treatment/Care

Undertaken

Patient Refered

Patient

Education/Explanation

Apology

Directed to

Staff

Good Supervision/Leadership

Good Team Work

Effective Communication

Relevant Person(s) Attended

Relevant Person(s) Educated

Good Luck/Chance

Mitigating

Factors

Directed to

Organisation

Effective Protocol Available

Product/Equipment/Device

Management &

Availability/Accessibility

Documentation Error

Corrected

Directed to an

Agent

Security/Physical

Environment Measure

Infection Control Strategies

Managed/Implemented

Therapeutic Agent Error

Corrected

Equipment Usage Error

Corrected

Other

33

Appendix 3. How this policy brief was prepared

The methods used to prepare this evidence brief are described in detail at these

references.(91-96)

The problem that this evidence brief addressed was identified through a survey of key

informants identified by Uganda’s Ministry of Health. These included policymakers,

researchers and other stakeholders. Further clarification was sought through a review of the

relevant documents, and discussions with the REACH Uganda Patient Safety Working

Group. Research describing the size and causes of the problem related to safety and quality of

care was identified through a review of government documents, routinely collected data,

electronic literature searches, contact with key informants, and reference lists of the relevant

documents retrieved.

Strategies used to identify potential options to address the problem included considering

interventions described in systematic reviews and other relevant documents, considering

ways in which other jurisdictions have addressed the problem, consulting key informants and

brainstorming. Potential barriers to implementing the policy options were identified through

brainstorming using a detailed checklist of potential barriers to implementing health

policies.(96)

We searched electronic databases using index terms or free text; PubMed, OVID, EMBASE,

PsychINFO, Health Systems Evidence, Cochrane Library, the Campbell Collaboration, DARE,

HTA databases, SUPPORT evidence summaries, and HINARI for full text articles of citations

identified. Grey literature sources that were searched included; OpenGREY, WHOLIS,

Google Scholar, national reports and government documents.

One of the authors summarised included reviews using an approach developed by the

Supporting the Use of Research Evidence (SURE) in African Health Systems project

(www.evipnet.org/sure).(94)

Drafts of each section of the report were discussed with the REACH Uganda Patient Safety

Working Group. The external review process of a draft version was managed by the authors.

Comments provided by the external reviewers and the authors’ responses are available from

the authors. A list of the people who provided comments or contributed to this policy brief in

many ways is provided in the acknowledgements section.


34

Glossary, Acronyms and Abbreviations:

WHO - World Health Organisation

EVIPNet - Evidence-Informed Policy Network (www.evipnet.org)

GRADE (Grading of Recommendations Assessment, Development and Evaluation) – a

system for rating the quality of evidence and the strength of recommendations

(www.gradeworkinggroup.org)

REACH - Regional East African Community Health (REACH) Policy Initiative

(www.eac.int/health)

SURE - Supporting the Use of Research Evidence (SURE) in African Health Systems

(www.evipnet.org/sure)

UN - United Nations

MOH - Ministry of Health

MDGs - Millenium Development Goals

HAI - Hospital Acquired Infection

ADE - Adverse Drug Events

DHS - Demographic Health Surveillance

The International Classification of Patient Safety (ICPS) provides the following

definitions:(12)

A patient safety incident is an event or circumstance that could have resulted, or did

result, in unnecessary harm to a patient. A patient safety incident can be a reportable

circumstance, a near miss, a no harm incident or a harmful incident (adverse event).

Incident type is a descriptive term for a category made up of incidents of a common

nature grouped because of shared, agreed features, such as ‘clinical process/procedure’

or ‘medication/IV fluid’ incident.

A patient outcome is the impact upon a patient, which is wholly or partially attributable

to an incident.

Contributing Factors/Hazards are the circumstances, actions or influences which are

thought to have played a part in the origin or development of an incident or to increase

the risk of an incident.

Organizational outcomes refer to the impact upon an organization which is wholly or

partially attributable to an incident such as an increased use of resources to care for the

patient, media attention or legal ramifications.

The concept of resilience in the context of the ICPS is defined as ‘the degree to which a

system continuously prevents, detects, mitigates or ameliorates hazards or incidents’ so

that an organization can ‘bounce back’ to its original ability to provide core functions.

http://www.evipnet.org/

http://www.gradeworkinggroup.org/

http://www.eac.int/health


35

Detection is defined as an action or circumstance that results in the discovery of an

incident. For example, an incident could be detected by a change in the patient’s status,

or via a monitor, alarm, audit, review or risk assessment.

Mitigating factors are actions or circumstances that prevent or moderate the

progression of an incident toward harming the patient.

Ameliorating actions are those actions taken or circumstances altered to make better

or compensate any harm after an incident.

Actions taken to reduce risk concentrate on steps taken to prevent the reoccurrence

of the same or similar patient safety incident and on improving system resilience.

Health care client: A health care client is anyone with an interest in the health care

system, such as a person who pays fees at a health care setting, a patient, a family

member, a family caregiver or a visitor exposed to the health care environment. (14)

Safe health care systems: Safe health care systems are those that incorporate

policies, protocols and process to assure the implementation of practices that based on

evidence safeguard the patient from preventable harm. (14)

36

References

1. Mulrow C. Rationale for Systematic Reviews. BMJ. 1994;309:597-9.

2. Bero L, Jadad A. How consumers and policymakers can use systematic reviews for decision making. Ann Intern Med 1997;127:37-42.

3. Oxman A, Bjørndal A, Becerra-Posada F, Gibson M, Block MG, Haines A. A framework for mandatory impact evaluation to ensure well informed public policy decisions. The Lancet. 2010;375:427–31.

4. Tumwesigye T, Hoyle S. The Kisiizi-Chester Journey 2009-2011. 2011.

5. MOH. Health Sector Quality Improvement Framework and Strategic Plan. In: Assurance Q, editor. Kampala, Uganda: Ministry of Health; 2011.

6. Nabudere H, Nsangi A. Survey Summary: terms of reference - patient safety evidence brief. Makerere University, 2013.

7. Jha A, Prasopa-Plaizier N, Larizgoitia I, Bates D. Patient safety research: an overview of the global evidence. BMJ Quality and Safety in Healthcare. 2010;19:42-7.

8. WHO. WHO Patient Safety Curriculum Guide for Medical Schools. In: Safety P, editor. Geneva, Switzerland: World Health Organisation; 2009.

9. WHO, editor Quality of Care: patient safety. Fifty-fifth World Health Assembly; 2002; Geneva, Switzerland: World Health Organisation.

10. Brennan T, Leape L, al. NLe. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine. 1991;324:370-6.

11. IOM. To Err is Human: Building a Safer Health System. Institute of Medicine, 1999 November 1999. Report No.

12. Sherman H, Castro G, Fletcher M. Towards an International Classification for Patient Safety: the conceptual framework. International Journal for Quality in Health Care. 2009;21(1):pp 2-8.

13. WHO. Everybody's Business: Strengthening Health Systems to Improve Health Outcomes. WHO's Framework for Action. Geneva, Switzerland: World Health Organisation; 2007.

14. WHO. Guide for Developing National Patient Safety Policy and Strategic Plan. Geneva, Switzerland: World Heath Organisation, Region WA; 2013 (pilot version).

15. WHO. Quality of Care: Patient Safety. Report by the Secretariat. Geneva, Switzerland: World Health Organisation; 2003.

16. WHO. Patient Safety: Proposal by Sir Liam Donaldson Geneva, Switzerland: World Health Organisation; 2003 [cited 2013 22 April 2013]. Available from: http://www.who.int/patientsafety/worldalliance/proposal/en/index.html.

17. WHO. Patient Safety: World Alliance for Patient Safety Geneva, Switzerland2004 [cited 2013 22 April 2013]. Available from: http://www.who.int/patientsafety/worldalliance/en/.

18. Kenya Ministry of Health Supports the World Health Organization Initiate Efforts to Tackle Patient Safety in Africa [press release]. Nairobi, Kenya: Ministry of Health, Republic of Kenya, 17 January 2005 2005.

19. WHO Conference Commits to Improving Patient Safety [press release]. Durban, South Africa: World Health Organisatin, January 2005 2005.

20. WHO. Make patient safety a priority in Africa, patients urge. Patients for Patient Safety News. 2011 July 2011.

21. WHO. African Partnerships for Patient Safety: safer care through international partnerships Geneva, Switzerland: World Health Organisation; 2013 [cited 2013 25 April 2013]. Available from: http://www.who.int/features/2013/uganda_patient_safety/en/.

22. UCMB. News from UCMB: Quality and Safety Desk. Kampala, Uganda: Uganda Catholic Medical Bureau, 2010 June 2010. Report No.

http://www.who.int/patientsafety/worldalliance/proposal/en/index.html

http://www.who.int/patientsafety/worldalliance/en/

http://www.who.int/features/2013/uganda_patient_safety/en/

37

23. UCMB. Progress on Patient Safety Initiatives. Kampala, Uganda: Uganda Catholic Medical Bureau, 2011.

24. UCMB. Quality and Patient Safety Management Guide. Kampala, Uganda: Uganda Catholic Medical Bureau, 2012.

25. MOH. Ministry of Health Kampala, Uganda2013. Available from: http://health.go.ug/mohweb/.

26. USAID. Uganda Delivery of Improved Services for Health (Dish) Facility Survey 2002. Chapel Hill, North Carolina, 2003 May 2003. Report No.

27. UMU. Uganda Martryrs University Namugongo, Uganda2013 [26 April 2013]. Available from: http://www.umu.ac.ug/.

28. IHSU. International Health Sciences University Namuwongo, Uganda2013 [26 April 2013]. Available from: www.ihsu.ac.ug/.

29. PASIMPIA. Patient Safety Improvement in Africa Kampala, Uganda2013 [14 March 2014]. Available from: http://pasimpia.org/.

30. RCQHC. Regional Centre for Quality of Health Care Makerere University, College of Health Sciences; 2014 [cited 2014 5 May 2014]. Available from: http://chs.mak.ac.ug/publichealth/content/regional-centre-quality-health-care.

31. Tumwikirize W, Ogwal-Okeng J, Vernby A, Anokbonggo W, Gustafsson L, Lundborg S. Adverse drug reactions in patients admitted on Internal Medicine wards in a district and Regional Hospital in Uganda. African Health Sciences. 2011;11(1):72-8.

32. Lubinga S, Uwiduhaye E. Potential drug-drug interactions on in-patient medication prescriptions at Mbarara Regional Referral Hospital (MRRH) in Western Uganda: prevalence, clinical importance and associated factors. African Health Sciences. 2011;11(3):499 - 507.

33. Ekwueme DU, Weniger BG, Chen RT. Model-based estimates of risks of disease transmission and economic costs of seven injection devices in sub-Saharan Africa. Bulletin of the World Health Organization. 2002;80:859-70.

34. Mishra V, Khan S, Liu L, Kottiri B. Medical Injection Use and HIV in Sub-Saharan Africa. . Calverton, Maryland, USA: Macro International Inc., 2008 October 2008. Report No.

35. EM L. Prevention of HIV transmission by blood transfusion in the developing world: achievements and continuing challenges. AIDS. 1998;12 (Suppl A:S81e6.).

36. Greco D, Magombe I. Hospital acquired infections in a large north Ugandan hospital. Journal for Prevention in Medicine and Hygiene. 2011;52(2):55-8.

37. MOH. Uganda Health Workforce: Satisfaction and Intent to Stay among Current Health Workers. . Kampala, Uganda: Ministry of Health, 2009.

38. MoH. Uganda Human Resources for Health Policy. Kampala: Ministry of Health; 2006.

39. Landrigan C, Rothschild J, al JCJe. Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine. 2004;351:1838-48.

40. Barger L, Cade B, al. NAe. Extended work shifts and the risk of motor vehicle crashes among interns. New England Journal of Medicine. 2005;352:125-34.

41. Luwedde M. Hospital Patient Safety Culture Survey. Kampala, Uganda: Uganda Catholic Medical Bureau, 2012.

42. Alaso A, Mbaasa A, Sekikubo J, Mpanga R, Namuddu SJF, Kadimba EG. Assessment of Error Reporting in Masaka Regional Referral Hospital, Masaka District. Kampala: Uganda Martyrs University, Nkozi; 2012.

43. Sethi AK, Acher CW, Kirenga B, Mead S, Donskey CJ, Katamba A. Infection control knowledge, attitudes, and practices among healthcare workers at Mulago Hospital, Kampala, Uganda. Infect Control Hosp Epidemiol. 2012;33(9):917-23.

44. Kiwanuka S, Ekirapa E, Peterson S, Okuia O, Rahmanc M, Peters D, et al. Access to and utilisation of health services for the poor in Uganda: a systematic review of available evidence. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2008;102:1067-74.

45. Peterson S, Nsungwa-Sabiiti J, Were W, Nsabagasani X, Magumba G, Nambooze J, et al. Coping with paediatric referral - Ugandan parents' experience. . Lancet. 2004(363):1955-6.

http://health.go.ug/mohweb/

http://www.umu.ac.ug/

http://www.ihsu.ac.ug/

http://pasimpia.org/

http://chs.mak.ac.ug/publichealth/content/regional-centre-quality-health-care

38

46. Selker H, Beshansky J, Pauker S, Kassirer J. The epidemiology of delays in a teaching hospital. Medical Care. 1989;27:112.

47. Shepperd S, McClaran J, Phillips C, Lannin N, Clemson L, McCluskey A, et al. Discharge planning from hospital to home (Review). Cochrane Database of Systematic Reviews. 2010;Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.CD000313.pub3.

48. Nankabirwa J, Zurovac D, Njogu JN, Rwakimari JB, Counihan H, Snow RW, et al. Malaria misdiagnosis in Uganda – implications for policy change. Malaria Journal. 2009;doi:10.1186/1475-2875-8-66.

49. WHO. Substandard and counterfeit medicines Geneva, Switzerland: World Health Organisation; 2003 [cited 2013 25 April 2013]. Available from: http://www.who.int/mediacentre/factsheets/2003/fs275/en/.

50. Nayyar GML, Breman JG, Newton PN, Herrington J. Poor-quality antimalarial drugs in Southeast Asia and Sub-Saharan Africa. Lancet Infect Dis. 2012;12:488–96.

51. Jaramogi P. Cabinet approves Anti-Counterfeit Bill. The New Vision. 2013 18 March 2013.

52. Butler M, Collins R, Drennan J, Halligan P, O’Mathúna DP, Schultz TJ, et al. Hospital nurse staffing models and patient and staff-related outcomes. Cochrane Database of Systematic Reviews. 2011(Issue 7. Art. No.: CD007019. DOI: 10.1002/14651858.CD007019.pub2.).

53. Ayre T, Gerdtz M, Parker J, Nelson S. Nursing skill mix and outcomes: a Singapore perspective. International Nursing Review. 2007;54::56–62.

54. UNMC. Uganda Nurses and Midwives Council Kampala, Uganda2014 [28 March 2014]. Available from: http://www.unmc.ug/approved_sch.html.

55. MOH. Human Resources for Health: Bi-Annual Report. Kampala, Uganda: Ministry of Health, 2013 March 2013. Report No.

56. MOH. Human Resources for Health Audit. Kampala, Uganda: Ministry of Health, 2009 May 2009. Report No.

57. MoH. Uganda Health Workforce: Satisfaction and Intent to Stay among Current Health Workers. Kampala: Ministry of Health, 2009.

58. Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Ditlopo P. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Services Research. 2008;8(247).

59. UBOS. Uganda National Household Survey - Socio Economic Findings. Kampala, Uganda: Uganda Bureau of Statistics, 2013.

60. AHRQ. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Santa Monica, California: Agency for Healthcare Research and Quality, 2013.

61. WHO. Declaration of Alma Ata: Report of the International Conference on Primary Health Care. Geneva, Switzerland: World Health Organisation, 1978.

62. Nilsen Elin S, Myrhaug Hilde T, Johansen M, Oliver S, Oxman Andrew D. Methods of consumer involvement in developing healthcare policy and research, clinical practice guidelines and patient information material. Cochrane Database of Systematic Reviews [Internet]. 2006; (3). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004563.pub2/abstract.

63. NORAD. SWAps and Civil Society: The Role of Civil Society Organisations in Uganda's Health Sector Programme. 2004 June 2003. Report No.

64. Nakibinge S, Maher D, Katende J, Kamali A, Grosskurth H, Seeley J. Community engagement in health research: two decades of experience from a research project on HIV in rural Uganda. Tropical Medicine and International Health. 2009;14(2):190–5.

65. UCHPSR. Uganda Clearinghouse for Health Policy and Systems Research Kampala, Uganda: UNHRO; 2013 [cited 2014 24 March 2014]. Available from: http://uchpsr.org/.

66. UNHCO. Uganda National Health Consumers Organisation Kampala, Uganda: UNHCO; 2013 [14 March 2014]. Available from: http://unhco.or.ug/about-3/.

67. UNHCO. Patient Feedback Mechanisms at Health Facilities in Uganda. Uganda National Health Consumers Organisation, 2003 August 2003. Report No.

http://www.who.int/mediacentre/factsheets/2003/fs275/en/

http://www.unmc.ug/approved_sch.html

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004563.pub2/abstract

http://uchpsr.org/

http://unhco.or.ug/about-3/

39

68. UNHCO. UNHCO Baseline Survey on Patients' Rights. Uganda National Health Consumers Organization, 2002 August 2002. Report No.

69. GOU. Patients Charter. Kampala: Ministry of Health 2009 December 2009. Report No.

70. Christensen M, Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database of Systematic Reviews [Internet]. 2013; (2). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008986.pub2/abstract.

71. HSC. Uganda Health Service Commission. Kampala2013.

72. Parmelli E, Flodgren G, Fraser SG, Williams N, Rubin G, Eccles MP. Interventions to increase clinical incident reporting in health care. Cochrane Database of Systematic Reviews. 2012(Issue 8. Art. No.: CD005609. DOI: 10.1002/14651858.CD005609.pub2.).

73. WHO. Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge. : World Health Organization; 2009 [cited 2014 02 March 2014]. Available from: http://www.who.int/gpsc/country_work/en/.

74. Gould DJ, Moralejo D, Drey N, Chudleigh JH. Interventions to improve hand hygiene compliance in patient care. Cochrane Database of Systematic Reviews. 2010; Issue 9. Art. No.: CD005186. DOI: 10.1002/14651858.CD005186.pub3.

75. Ejemot-Nwadiaro RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. . Cochrane Database of Systematic Reviews 2008(Issue 1. Art. No.: CD004265. DOI: 10.1002/14651858.CD004265.pub2.).

76. Flodgren G, Pomey M-P, Taber SA, Eccles MP. Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes. . Cochrane Database of Systematic Reviews

2011(Issue 11. Art. No.: CD008992. DOI: 10.1002/14651858.CD008992.pub2.).

77. Ketelaar NA, Faber MJ, Flottorp S, Rygh LH, Deane KH, Eccles MP. Public release of performance data in changing the behaviour of healthcare consumers, professionals or organisations. . Cochrane Database of Systematic Reviews. 2011(Issue 11. Art. No.: CD004538. DOI: 10.1002/14651858.CD004538.pub2.).

78. Telford R, Boote JD, Cooper CL. What does it mean to involve consumers successfully in NHS research? A consensus study. Health Expectations. 2004;7(3):209–20.

79. Cherrington DJ. Designing an effective recognition award program. Dispelling the myths. Clin Lab Manage Rev. 1993;7(3):201-4, 6-7.

80. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien Mary A, Wolf Fredric M, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews [Internet]. 2009; (2). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003030.pub2/abstract.

81. Lisby M, Thomsen A, Nielsen LP, Lyhne NM, Breum-Leer C, Fredberg U, et al. The effect of systematic medication review in elderly patients admitted to an acute ward of internal medicine. Basic & clinical pharmacology & toxicology. 2010;106(5):422-7.

82. Ivers N, Jamtvedt G, Flottorp S, Young Jane M, Odgaard-Jensen J, French Simon D, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews [Internet]. 2012; (6). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000259.pub3/abstract.

83. O'Brien Mary A, Rogers S, Jamtvedt G, Oxman Andrew D, Odgaard-Jensen J, Kristoffersen Doris T, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews [Internet]. 2007; (4). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000409.pub2/abstract.

84. Freemantle N, Harvey E, Wolf F, Grimshaw J, Grilli R, Bero L. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews [Internet]. 1997; (2). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000172/abstract.

85. Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes (update). Cochrane Database of Systematic Reviews


http://www.who.int/gpsc/country_work/en/




http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000172/abstract

40

[Internet]. 2013; (3). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002213.pub3/abstract.

86. Peñaloza B, Pantoja T, Bastías G, Herrera C, Rada G. Interventions to reduce emigration of health care professionals from low- and middle-income countries. Cochrane Database of Systematic Reviews [Internet]. 2011; (9). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007673.pub2/abstract.

87. AU. Abuja Declaration on HIV/AIDS. Tuberculosis and other related Infectious Diseases. Abuja, Nigeria: African Union, 2011 24-27 April 2001. Report No.

88. MOH. National Health Accounts: FY 2008/09 and FY 2009/10. Kampala, Uganda: Ministry of Health, 2013 March 2013. Report No.

89. Ernst Spaan, Mathijssen J, Tromp N, McBain F, Haveb At, Baltussena R. The impact of health insurance in Africa and Asia: a systematic review. Bulletin of the World Health Organisation. 2012(90):685–92A.

90. Ekman B. Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy and Planning. 2004;19(5):249–70.

91. Lavis JN, Wilson MG, Oxman AD, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 4: Using research evidence to clarify a problem. Health Research Policy and Systems. 2009;7(Suppl 1:S4).

92. Supporting the Use of Research Evidence (SURE) in African Health Systems. SURE guides for preparing and using policy briefs: 4. Clarifying the problem. .

93. Lavis JN, Wilson MG, Oxman AD, Grimshaw J, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 5: Using research evidence to frame options to address a problem. Health Research Policy and Systems. 2009;7 Suppl 1:S5.

94. Supporting the Use of Research Evidence (SURE) in African Health Systems. SURE guides for preparing and using policy briefs: 5. Deciding on and describing options to address the problem. .

95. Fretheim A, Munabi-Babigumira S, Oxman AD, Lavis JN, Lewin S. SUPPORT Tools for Evidence-informed Policymaking in health 6: Using research evidence to address how an option will be implemented. Health Research Policy and Systems. 2009;7 Suppl 1:S5.

96. Supporting the Use of Research Evidence (SURE) in African Health Systems. SURE guides for preparing and using policy briefs: 6. Identifying and addressing barriers to implementing the options. .



Improving Patient Safety for better Quality of Care · 1 10 May 2014 An Evidence Brief for Policy...

Documents

Transcript of Improving Patient Safety for better Quality of Care · 1 10 May 2014 An Evidence Brief for Policy...