Abstract
Background:
To explore interprofessionals’ perceptions about patient safety, particularly medication safety and associated factors and barriers.
Methods:
A total of 389 respondents were recruited using convenience sample in the cross sectional survey.
Results:
Medication safety was perceived as somewhat safe (60%). One-third of respondents witnessed 3–4 or more medication errors (MEs) within the past 1 year. Out of that, one quarter were reportedly, sentinel events. More sentinel events were witnessed in public hospitals and solo practice clinics compared with corporate hospitals and nursing homes (p < 0.02). No difference was observed in the occurrence of sentinel events in accredited and nonaccredited facilities (p = 0.30). Younger respondents witnessed more MEs, whereas accredited hospitals (mostly corporate hospitals) witnessed significantly fewer MEs and graded overall safety as ‘better’. However, most MEs go unreported particularly in solo practice clinics (88%) followed by nursing homes (67%), public hospitals (54%), and corporate hospitals (42%). Error identification and subsequent disclosure was inhibited by several system factors: fear of punitive action and lack of reporting systems. General surgical (46%), medical (42%), and paediatric units (36%), were the most error-prone places. Documentation diverted all healthcare workers from direct patient care. Many doctors and pharmacists from nursing homes, solo clinics and public hospitals reported working overtime. Staff shortages and poor training were overwhelming concerns to all healthcare workers and in public hospitals. Solo clinics and nursing homes perceived more barriers; lack of reporting systems, standard protocol, and resources for patient safety and unfamiliarity with prescribed medications was their overwhelming concern. Other factors threatening MEs were a lack of team approach and openness in interdisciplinary communications, illegible medical orders, and medicines prescribed by brand names.
Conclusions:
Immediate interventions to improve medication safety include enforcement of legible/printed medical orders in generic names, workforce development, developing standard protocols, and a corresponding change in organizational culture. Accreditation can serve as a driver for improving patient safety.
Keywords: frontline workers, medication errors, patient safety
Introduction
The concern for patient safety has become a priority issue in healthcare which is essential for quality patient care, employee welfare, and morale. Rapid changes in healthcare bring tremendous benefits to all; however, the occurrence of errors is possible and therefore mandates greater attention to safety. The landmark Institute of Medicine (IOM) report ‘To Err is Human’ placed this issue of preventable harm caused by medical errors and the huge wastage on the public and professional agenda [Kohn et al. 1999]. Then the second volume ‘Crossing the Quality Chasm’, asserted safe patient care and emphasized that errors result not only from provider carelessness and unique circumstances, but also from flawed processes and systems [IOM, 2001]. In 2004, the World Health Organization (WHO), fostered global awareness through the World Alliance for Patient Safety program, by releasing guidelines and strategies to encourage and promote practices that ensure patient safety, focusing on the best patient safety practices, as well as research initiatives [World Health Organization, 2004].
Medication errors (MEs) are associated with serious risks to patients. While there is not much data on patient safety from India, it remains a major public health issue for India, as well keeping in view the frequency of occurrence of MEs, and the complex and flawed patient care processes posing serious and considerable danger to patients in the hospitals. Recognizing that staff have a primary role in forming the safety culture, safety parameters of their work roles were defined by understanding hazards within the workplace [Kohn et al. 1999; Cooper, 2000]. While developed countries have already established national agencies to improve patient safety during healthcare delivery, the patient safety movement in India began with the Consumers Protection Act (CPA) of 1986 by bringing hospitals under its remit and holding professionals accountable for shortfalls in care. Though CPA stimulated awareness of the problem and encouraged safe practice, it also led to ‘defensive’ medicine and increased litigation in India. Patient safety received impetus in recent years due to accreditation of the hospitals, largely driven by medical tourism in India. The medical tourism hospitals increasingly make an effort to meet international accreditation standards and are adopting best practices to promote a culture of healthcare quality and safety. Internationally, the Joint Commission International, and nationally the Quality Council of India are advocating the National Accreditation Board of Hospitals (NABH) accreditation, though it is not mandatory at this time for all its hospitals in India.
Patient safety aims to reduce and prevent inadvertent harm caused to patients as a result of medical care. MEs are one of the most common patient safety adverse events posing serious risks to patients. Sources of errors include illegible prescription, dispensing errors, administration errors, calculation errors, monitoring errors. There is an association between a safety culture and safe patient care processes; the higher the MEs the more likely that there is a problem in the processes within a facility. Based on Donabedian’s Structure, Process, Outcome Model, it is hypothesized that higher patient safety culture scores are associated with a lower likelihood of MEs. A good patient safety system supports and encourages employees to report MEs and near misses. Despite widespread acknowledgement of the importance of medication safety, the subject is not always emphasized in undergraduate training. New graduates tended to make more MEs [Aitken et al. 2006] than older, more experienced nurses [Tang et al. 2007]. New graduates face many challenges as they begin their careers and are more stressed, adjusting to work environments especially with heavy workloads [Kovner and Schore, 1998; Spence Laschinger and Leiter, 2006; Spence Laschinger et al. 2009; Valdez, 2008].
Physicians, pharmacists, and nurses can be involved in the occurrence of MEs, therefore, measuring perceptions of these professionals is of great importance as they play a pivotal role in the implementation of safety guidelines. Several studies have been conducted regarding patient safety culture and differences between groups have also been reported [Sexton et al. 2006; Kim et al. 2007; Huang et al. 2007; Singer et al. 2007, 2009; France et al. 2010] but very few publications exist on the vital issue of patient safety in India [Chakravarty et al. 2015; Tetali et al. 2010; Balamurugan and Flower, 2014]. These studies were undertaken in different countries, contexts, healthcare systems, various disciplines, and professional ranks. The causes may also vary such as inexperienced or insufficient staff, or nonadherence to a procedure or protocol. No studies have been conducted in India eliciting the perception of frontline workers and demonstrating relationships between healthcare professionals’ characteristics. Therefore, the present study was conducted to gain a better understanding of interprofessional teams’ attitudes towards medication safety and to explore the relationship between the number of MEs, contributory factors, barriers, healthcare setting, type of practice and years of experience.
Methods
This cross-sectional study using convenience sampling was undertaken to survey doctors, nurses and pharmacists in the national capital region with at least 1 year experience. Consenting respondents working in public hospitals, corporate hospitals (privately owned), nursing homes (skilled nursing facilities for inpatients, providing medical care) or solo practice clinics (clinics operated by a single doctor) depending on their preference, anonymously filled responses either online (sent through a personally-unique link) or self-administered, with a data collector ensuring completion of any missing information before leaving. The study took place between December 2013 and January 2014. The study was deemed exempt from the Ethics Committee review.
The questionnaire was pretested before administration. The introductory survey page gave a brief introduction to the topic and the aim of the study, along with questions directed toward perception of MEs and safety, sources of error, error-reporting practices and demographic information. ME-reporting behaviour was examined by asking respondents to select from nine specific reasons for not reporting. They were asked to list factors which increase the likelihood of MEs from a checklist of 19 specific factors. Respondents were then asked to select what they perceived as the 5 most common barriers to improving safety from a checklist of 12 specific barriers and suggestions from a list of 8 suggestions with an open field to give further suggestions. Where possible, responses in the checklist were combined for analysis and any other category mentioned by the respondents was recoded into the respective checklist within the survey.
Data were analysed using the statistical package for the social sciences (SPSS) software, version 17. Pearson’s Chi-square test, Fisher’s test and an ANOVA were utilized to examine differences among different groups. The Chi-square test was used to analyse the proportions or the percentages of the categorical data; Fischer’s exact test was used whenever the cell frequency was <5. The quantitative data with more than two groups were analysed using the ANOVA test. A p value < 0.05 was considered statistically significant.
Results
A total of 389 respondents (189 doctors, 106 nurses and 94 pharmacists) participated in the study. The response rate was 77%. Respondents’ characteristics are shown in Table 1. Nurses were predominantly female whereas pharmacists were male. As regards education, most nurses and pharmacists had done a diploma whereas doctors had obtained a masters (63.5%) and bachelor degree (36.5%). Most respondents (88%) were directly involved in patient care, whereas the remainder were involved in other administrative jobs organizing patient care. The groups were stratified based on the healthcare professional category, hospital setting type, their accreditation status, years of experience and patient care area to understand the relationship between these variables on overall safety perception, occurrence of MEs, contributing factors, reporting, and barriers to improving patient safety. About 135 (35%) respondents [nurses 67 (63.2%), pharmacists 35 (37.2%), doctors 33 (17.5%)] belonged to an accredited work setting. Around 10% of the respondents were not aware of the accreditation.
Table 1.
General characteristics of the study subjects.
| Characteristics |
Doctors |
Nurses |
Pharmacists |
Total |
|---|---|---|---|---|
| n (%) | 189 (48.6) | 106 (27.2) | 94 (24.2) | n = 389 |
| Age (years) | ||||
| Mean ± SD | 30.77 ± 6.14 | 30.85 ± 7.51 | 29.84 ± 5.97 | 30.56 ± 6.5 |
| Range (years) | 22–52 | 21–65 | 22–51 | 21–65 |
| Sex | ||||
| Male | 136 (72%) | 6 (5.7%) | 86 (91.5%) | 228 (58.6%) |
| Female | 53 (28%) | 100 (94.3%) | 8 (8.5%) | 161 (41.4%) |
| Qualification | ||||
| Diploma | – | 92 (86.8%) | 69 (73.4%) | 161 (41.4%) |
| Bachelor’s degree | 69 (36.5%) | 14 (13.2%) | 16 (17%) | 99 (25.4%) |
| Master’s degree | 120 (63.5%) | – | 9 (9.6%) | 128 (33.3%) |
| Place of work | ||||
| Government hospital | 147 (77.8%) | 67 (63.2%) | 33 (35.1%) | 247 (63.5%) |
| Corporate hospital | 13 (6.9%) | 35 (33%) | 31 (33%) | 79 (20.3%) |
| Nursing home | 15 (7.9%) | 4 (3.8%) | 2 (2.1%) | 21 (5.4) |
| Solo clinic | 14 (7.4%) | – | 28 (29.8%) | 42 (10.89%) |
| Professional experience (years) | ||||
| Mean + SD | ||||
| <1 years | 34 (18%) | 10 (9.4%) | 12 (12.89%) | 56 (14.4%) |
| 1–5 years | 65 (34.4%) | 41 (38.7%) | 41 (43.6%) | 147 (37.8%) |
| 5–10 years | 53 (28%) | 20 (18.9%) | 22 (23.4%) | 95 (23.4%) |
| >10 years | 37 (19.6%) | 35 (33%) | 19 (20.2%) | 91 (23.4%) |
| Shifts normally worked | ||||
| Day | 84 (44.4%) | 24 (22.6%) | 62 (66%) | 170 (43.7%) |
| Night | 1 (5%) | 3 (2.8%) | 1 (1.1%) | 5 (1.3%) |
| Rotator | 104 (55%) | 79 (74.5%) | 31 (33%) | 214 (55%) |
| Hours of work per week | ||||
| <20 h | 4 (2.1%) | – | 2 (2.1%) | 6 (1.5%) |
| 20–40 h | 19 (10.1%) | 11 (10.4%) | 18 (19.1%) | 48 (12.3%) |
| 40–60 h | 76 (40.2%) | 75 (70.8%) | 38 (40.4%) | 189 (48.6%) |
| 60–80 h | 62 (32.8%) | 18 (17%) | 21 (22.3%) | 101 (26%) |
| 80–100 h | 24 (12.7%) | 2 (1.9%) | 13 (13.8%) | 39 (10%) |
| >100 h | 4 (2.1%) | – | 2 (2.1%) | 6 (1.5%) |
| Primary work area | ||||
| OPD/diagnostics | 16 (8.5%) | 1 (0.9%) | – | 17 (4.4%) |
| Medical | 43 (22.8%) | 13 (12.3%) | 4 (4.3%) | 60 (15.4%) |
| Surgical/anaesthesia/obstetrics and gynaecology | 44 (23.3%) | 25 (23.6%) | 1 (91.1%) | 70 (18%) |
| ICU/emergency | 8 (4.2%) | 25 (23.6%) | – | 33 (25%) |
| Many different areas | 15 (7.9%) | 23 (21.7%) | 4 (4.3%) | 42 (10.8%) |
| Paediatrics | 56 (29.6%) | 18 (17%) | – | 74 (19%) |
| Pharmacy | 7 (3.7%) | 1 (0.9%) | 85 (90.4%) | 93 (23.9%) |
h, hour; ICU, intensive care unit; OPD, ; SD, standard deviation.
Overall perception of medication safety
Tables 2 and 3 depict safety perception and the extent of reporting of MEs by different healthcare workers and in different healthcare work settings respectively. The perception of overall safety of medication use compared with 1 year ago by different healthcare workers was perceived ‘as better’ by 40%, [mostly by nurses (55%) and pharmacists (48%)] whereas 58% reported no change [mostly doctors (70%) by Fischer’s exact test p < 0.000]. Most respondents [233 (60.2%)] graded overall patient safety ‘as acceptable’ (p < 0.000). The majority (60%) felt ‘somewhat safe’ in any hospital, however, when asked the same question about their own hospital, staff in all healthcare categories felt safer in their own hospital. There was no difference between the perceptions of different healthcare staff categories. As regards overall safety, 41 (51.9%) of respondents graded it as ‘very safe’ in corporate hospitals compared with ‘acceptable’ in solo practice clinic (34, 82.9%), public hospitals (165, 67%), nursing home (12, 57.1%; Chi-square test p < 0.000). None from nursing homes and solo clinics were graded as ‘excellent’ (p < 0.000).
Table 2.
Healthcare workers’ perception of safety in hospital, medication errors witnessed and reported.
| Doctors (189; 48.6%) | Nurses (106; 27.2%) | Pharmacists (94; 24.2%) | Total (n = 389) | p value | |
|---|---|---|---|---|---|
| Overall safety of medicines rating compared with 1 year ago | |||||
| Better | 51 (27%) | 58 (54.7%) | 45 (47.9%) | 154 (39.6%) | 0.000 |
| Neither better nor worse | 132 (69.8%) | 45 (42.5%) | 49 (52.1%) | 226 (58.1%) | |
| Worse | 6 (3.2%) | 3 (2.8%) | – | 9 (2.3%) | |
| Overall safety grade | |||||
| Excellent | 4 (2.1%) | 7 (6.7%) | 8 (8.6%) | 19 (4.9%) | 0.000 |
| Very safe | 55 (29.1%) | 37 (35.2%) | 27 (29%) | 119 (30.7%) | |
| Acceptable | 122 (64.6%) | 57 (54.3%) | 54 (58.1%) | 233 (60.2%) | |
| Unsafe | 8 (4.2%) | 4 (3.8%) | 4 (4.3%) | 16 (4.1%) | |
| Overall safety perception in your hospital | |||||
| Extremely safe | 2 (1.1%) | 13 (12.3%) | 11 (11.7%) | 26 (6.7%) | 0.005 |
| Very safe | 78 (41.3%) | 39 (36.8%) | 37 (39.4%) | 154 (39.6%) | |
| Somewhat safe | 99 (52.4%) | 51 (48.1%) | 41 (43.6%) | 191 (49.1%) | |
| Unsafe | 8 (4.2%) | 1 (0.9%) | 4 (4.3%) | 13 (3.3%) | |
| Not safe at all | 2 (1.1%) | 2 (1.9%) | 1 (1.1%) | 5 (1.3%) | |
| Overall safety perception in any hospital | |||||
| Extremely safe | – | 9 (8.5%) | 8 (8.5%) | 17 (4.4%) | 0.000 |
| Very safe | 28 (14.8%) | 34 (32.1%) | 27 (28.7%) | 89 (22.9%) | |
| Somewhat safe | 133 (70.4%) | 53 (50%) | 46 (48.9%) | 232 (59.6%) | |
| Unsafe | 24 (12.7%) | 8 (7.5%) | 12 (12.8%) | 44 (11.3%) | |
| Not safe at all | 4 (2.1%) | 2 (1.9%) | 1 (1.1%) | 7 (1.8%) | |
| Number of medication errors witnessed | |||||
| None | 71 (37.6%) | 49 (46.2%) | 54 (57.4%) | 174 (44.7%) | 0.000 |
| 1–2 | 71 (3.7%) | – | – | 4 (1%) | |
| 3–4 | 64 (33.9%) | 47 (44.3%) | 18 (19.1%) | 129 (33.2%) | |
| 5–10 | 30 (15.9%) | 9 (8.5%) | 12 (12.8%) | 51 (13.1%) | |
| 10+ | 17 (8.9%) | 1 (0.9%) | 10 (10.6%) | 28 (7.2%) | |
| Number of sentinel events witnessed | |||||
| None were sentinel | 134 (70.9%) | 81 (76.4%) | 73 (77.7%) | 288 (74%) | 0.525 |
| 25% were sentinel | 39 (20.6%) | 18 (17%) | 14 (14.9%) | 71 (18.3%) | |
| 50% were sentinel | 16 (8.5%) | 6 (5.7%) | 7 (7.4%) | 29 (7.5%) | |
| 75% were sentinel | – | 1 (9%) | – | 1 (3%) | |
| All were sentinel | – | – | – | – | |
| % of medication errors reported | |||||
| All | 23 (12.2%) | 14 (13.2%) | 12 (12.8%) | 49 (12.6%) | 0.592 |
| Some | 60 (31.7%) | 38 (35.8%) | 24 (25.5%) | 122 (31.4%) | |
| None | 106 (56.1%) | 54 (50.9%) | 58 (61.7%) | 218 (56%) | |
| Place accredited by any agency such as NABH, JCI | |||||
| Yes | 33 (17.5%) | 67 (63.2%) | 35 (37.2%) | 135 (34.7%) | 0.000 |
| No | 141 (74.6%) | 25 (23.6%) | 51 (54.3%) | 217 (55.8%) | |
| Do not know | 15 (7.9%) | 14 (13.2%) | 8 (8.5%) | 37 (9.5%) | |
JCI, Joint Commission International; NABH, National Accreditation Board of Hospitals.
Table 3.
Overall perception of safety in the hospitals in different healthcare settings.
| Government hospital (247, 63.5%) | Corporate hospital (79, 20.3%) | Nursing home (21, 5.4%) | Solo clinics (42, 10.8%) | Total (389, 100%) | p value | |
|---|---|---|---|---|---|---|
| Overall safety of medicines rating compared with 1 year ago | ||||||
| Better | 94 (38.1%) | 55 (69.6%) | 3 (14.3%) | 2 (4.8%) | 154 (39.6%) | 0.000 |
| Neither better nor worse | 145 (58.7%) | 23 (29.1%) | 18 (85.7%) | 40 (95.2%) | 226 (58.1%) | |
| Worse | 8 (3.2%) | 1 (1.3%) | – | – | 9 (2.3%) | |
| Overall safety grade | ||||||
| Excellent | 6 (2.4%) | 13 (16.5%) | – | – | 19 (4.9%) | 0.000 |
| Very safe | 64 (26%) | 41 (51.9%) | 9 (42.9%) | 5 (12.2%) | 119 (30.7%) | |
| Acceptable | 165 (67.1%) | 22 (27.8%) | 12 (57.1%) | 34 (82.9%) | 233 (60.2%) | |
| Unsafe | 11 (4.5%) | 3 (3.8%) | – | 2 (4.9%) | 16 (4.1%) | |
| Overall safety perception in your hospital | ||||||
| Extremely safe | 11 (4.5%) | 15 (19%) | – | – | 26 (6.7%) | 0.000 |
| Very safe | 80 (32.4%) | 50 (63.3%) | 8 (38.1%) | 16 (38.1%) | 154 (39.6%) | |
| Somewhat safe | 144 (58.3%) | 12 (15.2%) | 13 (61.9%) | 22 (52.4%) | 191 (49.1%) | |
| Unsafe | 8 (3.2%) | 2 (2.5%) | – | 3 (7.1%) | 13 (3.3%) | |
| Not safe at all | 4 (1.6%) | – | – | 1 (2.4%) | 5 (1.3%) | |
| Overall safety perception in any hospital | ||||||
| Extremely safe | 4 (1.6%) | 13 (16.5%) | – | – | 17 (4.4%) | 0.000 |
| Very safe | 48 (19.4%) | 39 (49.4%) | 1 (4.8%) | 1 (2.4%) | 89 (22.9%) | |
| Somewhat safe | 166 (67.2%) | 19 (24.1%) | 15 (71.4%) | 32 (76.2%) | 232 (59.6%) | |
| Unsafe | 23 (9.3%) | 8 (10.1%) | 5 (23.8%) | 8 (19%) | 44 (11.3%) | |
| Not safe at all | 6 (2.4%) | – | – | 1 (2.4%) | 7 (1.8%) | |
| Number of medication errors witnessed | ||||||
| None | 96 (38.9%) | 29 (36.7%) | 12 (57.1%) | 37 (88.1%) | 174 (44.7%) | 0.000 |
| 1–2 | 7 (2.8%) | – | – | – | 7 (1.8%) | |
| 3–4 | 79 (32%) | 41 (51.9%) | 5 (23.8%) | 5 (23.8%) | 129 (33.2%) | |
| 5–10 | 41 (16.6%) | 7 (8.9%) | 2 (9.5%) | 2 (9.5%) | 51 (31.1%) | |
| 10+ | 24 (9.7%) | 2 (2.5%) | 2 (9.5%) | – | 28 (7.2%) | |
| Number of sentinel events witnessed | ||||||
| None were sentinel | 169 (68.4%) | 64 (81%) | 15 (71.4%) | 40 (95.2%) | 288 (74%) | 0.023 |
| 25% sentinel | 53 (21.5%) | 13 (16.5%) | 3 (14.3%) | 2 (4.8%) | 71 (18.3%) | |
| 50% sentinel | 24 (9.7%) | 2 (2.5%) | 3 (14.3%) | – | 29 (7.5%) | |
| 75% sentinel | 1 (0.4%) | – | – | – | 1 (0.3%) | |
| All sentinel | – | – | – | – | ||
| % of medication errors reported | ||||||
| All | 36 (14.6%) | 12 (15.2%) | – | 1 (2.4%) | 49 (12.6%) | 0.000 |
| Some | 77 (31.2%) | 34 (43%) | 7 (33.3%) | 4 (9.5%) | 122 (31.4%) | |
| None | 134 (54.3%) | 33 (41.8%) | 14 (66.7%) | 37 (88.1%) | 218 (56%) | |
| Place accredited by any agency such as NABH, JCI | ||||||
| Yes | 67 (27.1%) | 60 (75.9%) | 5 (23.8%) | 3 (7.1%) | 135 (34.7%) | 0.000 |
| No | 152 (61.5%) | 18 (22.8%) | 15 (71.4%) | 32 (76.2%) | 217 (55.8%) | |
| Do not know | 28 (11.3%) | 1 (1.3%) | 1 (4.8%) | 7 (16.7%) | 37 (9.5%) | |
JCI, Joint Commission International; NABH, National Accreditation Board of Hospitals.
Though only one-third of respondents belonged to an accredited hospital, they scored overall safety as better [‘very safe’ (63, 46.7%) and ‘excellent’ (10, 7.4%); Chi-square test p < 0.000]. Similarly, most healthcare staff with 1–5 years’ experience rated patient safety as ‘acceptable’ (66, 61%) and ‘very safe’ (37, 34.3%). Healthcare professionals having more than 10 years of experience had a more positive perception about patient safety in their own hospital (Chi-square test p < 0.02).
Occurrence of medication errors
Despite perceived improvements, one-third of respondents witnessed 3–4 MEs or more within the past 1 year, but most MEs were not reported (Table 2). About 174 respondents (45%) did not witness any ME. Out of MEs witnessed one quarter were reportedly sentinel events. The number of sentinel events were higher in public hospitals and solo practice clinics compared with corporate hospitals and nursing homes (Fischer’s exact test p < 0.02) but there was no statistically significant difference between the occurrence of sentinel events in accredited and nonaccredited health facilities (Chi-square test p = 0.30). Younger staff (having 1–5 years of experience) witnessed significantly more MEs (p < 0.009). Significantly more errors were witnessed by those working in a general surgical unit, intensive care/critical care, operation theatre, general medical and paediatric unit (Fischer’s exact test p < 0.004). Similarly, staff working at night (60%) or rotating shifts (41%) experienced significantly more MEs (Fischer’s exact test p < 0.000). Overall, MEs are either not reported 49 (12.6%) or only some are reported 122 (31.4%). There was a significant difference in the number of MEs reported according to different health care settings (Fischer’s exact test p < 0.000). MEs are not reported by solo practice clinics (88%), nursing homes (67%), public hospitals (54%) and corporate hospital (43%). Respondents from accredited hospitals though, witnessed significantly fewer MEs (p < 0.000) but even in accredited hospitals, not all MEs (>50%) were reported compared with nonaccredited health facilities (Fischer’s exact test p < 0.14).
Reasons for not reporting medication errors
In the present study most MEs are not reported, though corporate hospitals have better reporting systems (Fischer’s exact test p = 0.000) but there was no significant difference between different healthcare workers (Fischer’s exact test p = 0.592). Major reasons for not reporting MEs were similar across different healthcare settings and all healthcare staff and included: lack of awareness of ‘what constitutes an ME’, ‘lack of a system for reporting’ and ‘when should MEs be reported’. However, these were more of concern for solo practice clinics and nursing homes as awareness about MEs and requirement for reporting are not clear to them. Others cited fear of punitive action especially in public hospitals and a lack of a system for reporting and analyzing incident reports and feedback to staff. Even in corporate hospitals, 33% expressed fear of punitive action against them.
Factors responsible for medications errors
Factors responsible for MEs and major reasons for not reporting errors are depicted in Figure 1 and Figure 2, respectively. Key barriers for improving patient safety are depicted in Table 4 and Table 5 by different healthcare staff and in different healthcare settings respectively. Staff shortage was a universal key barrier across all professionals and set-ups but was of more concern in public hospitals (75%) followed by corporate hospitals (57%) and nursing homes (52%). This barrier was followed by a lack of standard protocols. Other barriers to improve safety were of lesser concern for respondents from public hospitals and corporate hospitals compared with nursing homes and solo practice clinics. Unfamiliarity with a medication was overwhelmingly perceived as a barrier in the nursing home (90%) and solo clinic (82%) setting. Other predominant barriers of solo practice clinics were a lack of a system for reporting of errors and resources (human and monetary) specifically allocated for patient safety (63%).
Figure 1.
Factors responsible for medication errors.
LASA, look alike sound alike.
Figure 2.
Reasons for not reporting medication errors all respondents.
ME, medication errors.
Table 4.
Key barriers to improve patient safety experienced by different healthcare professionals.
| Key barriers to improve patient safety |
Doctors |
Nurses |
Pharmacists |
Total |
|---|---|---|---|---|
| n (%) | 189 (48.6%) | 106 (27.2%) | 94 (24.2%) | 389 |
| Shortage of staff | 103 (54%) | 66 (62%) | 54 (57%) | 223 (57%) |
| Lack of standard protocols, | 74 (39%) | 23 (22%) | 12 (13%) | 109 (28%) |
| Unfamiliarity with a medication | 63 (33%) | 22 (21%) | 30 (32%) | 115 (30%) |
| Lack of system for reporting of errors | 54 (29%) | 25 (24%) | 24 (26%) | 103 (26%) |
| Lack of hospital management commitment | 50 (26%) | 10 (9%) | 19 (20%) | 79 (20%) |
| Lack of team approach | 45 (24%) | 16 (15%) | 9 (10%) | 70 (18%) |
| Poor undergraduate training | 45 (24%) | 12 (11%) | 27 (29%) | 84 (22%) |
| Lack of openness in interdisciplinary communications | 45 (24%) | 4 (4%) | 19 (20%) | 68 (17%) |
| Lack of continuity of care | 40 (21%) | 5 (5%) | 12 (13%) | 57 (15%) |
| Lack of access to clinical information | 35 (19%) | 2 (2%) | 15 (16%) | 52 (13%) |
| Lack of resources (human and monetary) specifically allocated for patient safety initiatives | 33 (17%) | 9 (8%) | 17 (18%) | 59 (15%) |
| Lack of automatic notification of significant patient issues | 14 (7%) | 5 (5%) | 8 (9%) | 27 (7%) |
Table 5.
Key barriers to improve patient safety experienced in different healthcare set-ups.
| Key barriers to improve patient safety |
Government hospital |
Corporate hospital |
Nursing home |
Solo clinic |
Total |
|---|---|---|---|---|---|
| n (%) | 247 (63.50%) | 79 (20.30%) | 21 (5.4%) | 42 (10.8%) | 389 (100%) |
| Shortage of staff | 174 (75%) | 38 (56.7%) | 11 (52.4%) | 12 (31.6%) | 235 (61.5%) |
| Lack of standard protocols | 77 (31.8%) | 14 (17.7%) | 12 (57.1%) | 21 (52.5%) | 124 (32.5%) |
| Lack of system for reporting of errors | 68 (28.1%) | 18 (22.8%) | 3 (14.3%) | 25 (62.5%) | 114 (29.8%) |
| Lack of resources (human and monetary) specifically allocated for patient safety | 68 (28.1%) | 18 (4.7%) | 3 (14.3%) | 25 (62.5%) | 114 (29.8%) |
| Unfamiliarity with a medication | 58 (25%) | 10 (14.9%) | 19 (90.5%) | 31 (81.6%) | 118 (30.9%) |
| Lack of team approach | 54 (23.3%) | 15 (22.4%) | 5 (23.8%) | 4 (10.5%) | 78 (20.4%) |
| Lack of hospital management commitment | 45 (19.4%) | 12 (17.9%) | 8 (38.1%) | 17 (44.7%) | 82 (21.5%) |
| Poor undergraduate training | 45 (19.4%) | 17 (25.4%) | 6 (28.6%) | 21 (55.3%) | 89 (23.3%) |
| Lack of openness in interdisciplinary communications | 42 (18.1%) | 9 (13.4%) | 5 (23.8%) | 15 (39.5%) | 71 (18.6%) |
| Lack of continuity of care | 38 (16.4%) | 6 (9%) | 5 (23.8%) | 12 (31.6%) | 61 (16%) |
| Lack of access to clinical information | 31 (13.4%) | 8 (11.9%) | 3 (14.3%) | 10 (26.3%) | 52 (13.6%) |
| Lack of automatic notification of significant patient issues | 17 (7%) | 2 (2.5%) | 2 (9.5%) | 8 (20%) | 29 (7.6%) |
Documentation (42%) is the single most time-consuming task that diverts all categories of staff from direct patient care followed by administrative work (18%) leaving insufficient time to complete patient care tasks safely. Overall, 38% of respondents reported working overtime (>60 h/week), with half working between 40–60 h on average per week. More than 70% of respondents (mainly doctors and pharmacists) working especially in nursing homes and solo practice clinics worked for 60–80 h or more. Some (7%) worked for even more than 100 h in solo practice clinics. Around 40% doctors working in public hospitals also reported working overtime (for >60 h/week). Of those doctors and pharmacists regularly working overtime, about 50% identified documentation as the primary cause of overtime, followed by administrative work (22%).
Reasons and suggestions for improving patient safety
Overwhelmingly all respondents across different healthcare staff categories credited better communication between healthcare providers as the key reason for improvement. Other reasons cited included sensitization and awareness of staff about MEs (89, 23.7%), management support for examining errors and ways to avoid them (49, 13.1%), enforcement of reporting requirements for MEs by the accrediting body (48, 12.8%), established system of reporting MEs (44, 11.7%). Only a few respondents (37, 9.9%) cited implementation of technology that helps reduce MEs as a reason for this improvement.
When asked about suggestions to improve patient safety, again all respondents suggested improving communication between healthcare providers across work areas and continuing education on new medications. About 210 [54%; (nurses 81%; doctors 48.7%)] suggested sharing patient safety concerns/system defects and their resolutions among departments/units to promote learning in the organization. Other suggestions included computer systems that could capture patient information, generate alerts automatically (147, 38.7%), continuously reinforcing patient safety as a priority (150, 38.6%), personnel are not punished for errors reported through incident reports (132, 33.9%), develop a facility-wide patient safety program (83, 21.3%).
When asked for one aspect of the job to be changed that could help them the most, 41% selected error-proofing by computer-generated automatic alerts if there is any error in the prescription (e.g. drug, dose or strength), 30% selected prescriptions written in generic names, and 29% selected prescriptions written in legible hand writing. Doctors (50%) selected error-proofing by computer systems, while nurses (43%) chose prescriptions written in legible hand writing and pharmacists (50%) selected prescriptions written in generic names would help to improve patient safety.
Discussion
The aim of the present study was to investigate the perception of safety with special reference to MEs among frontline healthcare staff. Despite its limitation of study design and sample population, the results do provide insights into various factors threatening MEs and the impact of education and experience on ME rates. Despite a patient safety movement persuading hospitals to improve safety in India, medication safety is still a concern for healthcare providers, as most healthcare staff categories graded patient safety as ‘acceptable’, except corporate hospitals who perceived it as ‘very safe’ or ‘somewhat safe’ similar to a report by Balamurugan and Flower, reflecting low levels of reliability of organization [Balamurugan and Flower, 2014]. In the present study younger staff witnessed more MEs and rated overall safety as acceptable only. Although relevance is limited in the Indian healthcare setting, these findings are similar to reports where new graduates tended to make more MEs [Aitken et al. 2006] than older, more experienced nurses [Tang et al. 2007]. New graduates were less positive about their work environment because they are more stressed adjusting to the work environment [Kovner and Schore, 1998; Spence Laschinger et al. 2009], emotionally exhausted due to staffing inadequacy [Spence Laschinger and Leiter, 2006], or overwhelmed [Valdez, 2008] adversely affecting patient outcomes. Chakravarty and colleagues also reported postgraduate residents and nursing personnel were more stressed and fatigued compared with higher stress resilience among clinicians [Chakravarty et al. 2015]. Rigorous training, prolonged exposure to critical care interventions coupled with an orientation to the unit and a formal transition to the practice programme may contribute to higher stress resilience and transitioning of new graduates to the full professional role. Novice graduates, without much experiential learning, are not able to pick up subtle changes; may miss signs of life-threatening conditions or omit key aspects of care, thereby missing the bigger picture. Therefore, this aspect needs to be addressed as a priority by suitable and sustained hospital-wide improvement efforts.
In the present study, safety perception varied between interprofessionals, patient care area, working hours, professional experience, work set-up (public or private), and accreditation status. Significantly higher MEs were witnessed by those working in a general surgical unit, general medical unit, paediatric unit, intensive care/critical care, and those working in many different patient care areas. One quarter were reportedly sentinel events but most MEs were not reported particularly from nursing homes and solo practice clinics. Perhaps in these settings, any error is seen as negligence on the part of the provider, discouraging openness and thus learning.
Respondents from accredited hospitals (mostly corporate hospitals) witnessed significantly fewer MEs and graded overall safety as ‘better’. The reason for this could be sensitization of the staff to various patient safety issues such as error-prone processes, requirements for reporting of MEs and analysis of the reports by dedicated quality and safety officers. NABH has incorporated patient safety performance in its standards, and accredited corporate hospitals and a few apex institutes have started with patient safety activities like incident reporting, analysis of sentinel events, training and education programme for employees. However, in the majority of hospitals the approach is still far from satisfactory. Accreditation could be a driver for patient safety but is yet to pick up in public hospitals, nursing homes and solo practice clinics as it is voluntary at this time.
In the present study most MEs are not reported and also reasons for not reporting are also similar across different healthcare settings. Overall awareness about MEs and a lack of reporting systems was low especially among solo practice clinics and nursing homes. Though corporate hospitals have better reporting systems but the fear of punitive action is still a concern for them. In public hospitals fear of punitive action and a lack of a system for reporting and analysing incident reports and feedback to the staff were the major reason for not reporting MEs. The attitude of some respondents that ‘only serious MEs need to be reported’ or ‘it does not matter if an ME is not reported’ raise serious concerns further emphasising the need for increasing awareness about medication safety and using ME reporting as an educational tool, resolving error incidents, and improving care, therefore, need the creation of a blame-free environment for reporting errors similar to a report by Balamurugan and Flower [Balamurugan and Flower, 2014]. The more positive a safety culture the more willing employees are to report [Helmreich and Merritt, 1998; Reason, 2002]. Other studies indicated that measuring safety culture will help managers understand the impact of safety culture on the occurrence of errors and to identify the relative contribution of causal factors to errors [Hofmann et al. 2003; O’Toole, 2002].
As reported in the present study, and studies by Tetali and colleagues and the McKesson Corporation, the impact of staff shortages (many hospitals face high turnover and chronic shortages in the ranks of nurses and junior doctors) are overwhelming concerns to all healthcare workers and in all settings [Tetali et al. 2010; McKesson Corporation, 2005]. Thus, improved mandatory staff-to-patient ratios are critical for improving patient safety.
Errors were more likely to occur because of a lack of team approach, illegible medical orders, poor education and training, unfamiliarity with the medication being administered, and lack of openness in interdisciplinary communications due to communication breakdowns. Other times identified as prime for errors by all healthcare professionals and set-ups included medicines written by brand names, confusion between look alike and sound alike (LASA) medicines, lack of orientation of new staff, and lack of standard protocols. These findings are consistent with reports from other studies [Chakravarty et al. 2015; McKesson Corporation, 2005].
Poor education and training were cited as factors contributing to MEs as well as barriers by all and have implications for current and prospective healthcare staff, hospital administrators, policy makers, and educators in identifying education and training gaps relevant to practice requirements. The existing curriculum of all healthcare staff categories does not provide adequate knowledge and competencies for the jobs they are required to do for patient safety. The entry level qualification of nurses and pharmacists in India is only a diploma, as observed in the present study that most nurse and pharmacist respondents were diploma holders. A diploma of nursing and pharmacy is offered as an alternative to a bachelor’s degree by any private educational, vocational institution or polytechnic which differs not only in the time it takes to earn credits required in order to graduate (usually longer duration 3–4 years by an accredited university) but also differs in the focus and aims. Moreover, the quality of graduates in India’s medical, nursing and pharmacy schools is variable. To a large extent on-the-job experience enables a fresh graduate to become ‘safe providers’ since younger providers experienced more MEs. Therefore, there is an urgent need for incorporating patient safety in the graduate programme curriculum and raising entry qualifications of nurses and pharmacists from diploma to degree course or provide regular preservice induction training supplemented with in-service on-the-job training to create an effective workforce for safe healthcare delivery.
While a lack of team approach acts a barrier, the same can facilitate cohesion, team spirit and collaboration among healthcare workers and positively impacts the effectiveness of care, patient safety and clinical outcomes. Chakravarty and colleagues also reported lower perception in teamwork among postgraduate residents, nurses and paramedical workers compared with the clinicians, probably reflecting deficiencies in co-operation and interpersonal relations among members of healthcare teams [Chakravarty et al. 2015]. On the other hand, often different consultants within a specialty in a hospital insist on different pathways for ‘their’ patients’ thus increasing complexity and the chances of error. [Clancy, 2007; Abdou and Saber, 2011]. It is clear that hospitals must develop standard protocols and effective processes for transferring medication knowledge to frontline workers; especially availability of information at the point-of-care to assist nurses/pharmacists when administering/dispensing unfamiliar medications, and safeguards to help ensure proper use of medications.
Improved communication between healthcare providers was cited as the major reason for improvement in medication safety. Deficits in communication and information transfer during shifting from one patient care area to another or at hospital discharge are common and may adversely affect patient care. Electronic health records can facilitate timely transfer of pertinent patient information to other healthcare providers.
Nurses overwhelmingly were concerned about legibility of the prescription whereas prescriptions written by brand name combined with illegible hand writing were a major concern of the pharmacists. All healthcare providers reported documentation as the single most time consuming task followed by administrative work which diverted them from direct patient care and as the primary cause of working overtime, thus raising the likelihood of adverse events and errors in healthcare. Many doctors working in nursing homes, solo practice clinics and public hospitals reported working overtime. In India though the legal work week consists of 48 h/week for government employees, and to some extent in the organized sector, but real work week varies. Staff shortage is usually overcome by assigning more working hours to ensure coverage of patient needs. Staff shortages (limiting the time spent per patients), working overtime, and night shifts are all linked with a risk of attentional failures and adverse events. In this present study also more MEs were experienced by younger staff and those working in the night or on a rotating shift. Olds and Clarke reported a significant relationship between nurses working for more than 40 h in the average week and adverse events and errors [Olds and Clarke, 2010]. Computers can help spare frontline workers’ time especially doctors allowing more time for patient care activities by assisting with organizational, administrative duties, and updating patient records, including past treatment. Contrary to common reports that frontline workers are averse to using new technologies, all healthcare workers (especially doctors) suggested technology would play a positive role in patient safety that could help them deliver safer care more effectively and efficiently. Error-proofing with computers can firstly serve as a safety net or ‘double check’ to make sure medications are prescribed and administered correctly by preventing transcription errors while copying medical orders and difficulties with illegible medical orders, especially concerning LASAs and branded medications. However, utilization of technology in preventing MEs still remains remarkably low, as hospitals still work in a paper world. Resources should be specifically allocated for patient safety initiatives such as patient safety education, data collection and analysis, and technology and equipment which can help healthcare staff manage the work better.
Limitations
This was a cross-sectional study, and the causal direction of the variables used in the study cannot be determined. Second, the study was conducted among a variable group of health professionals working in different set-ups. Motivation levels of the respondents and social desirability biases may also affect the responses since decision to participate or not is affected by several factors, including the respondent’s attitude towards patient safety, whether the workplace organization recognizes and gives importance to this issue or any misinterpretation of questions. Use of a convenience sample is often associated with a selection bias that may limit the generalizability of the results, since a greater percentage of doctors from the public sector participated in the study. Future studies that use a probability sample design may increase the likelihood of the sample being representative of the population.
Conclusion
There is a need to adopt multiple strategies as differences in perceptions do exist between different healthcare professionals and barriers faced by them. Lack of a team approach, standard protocol, a system for reporting of errors, hospital management commitment, poor education and lack of continuity of care are top key barriers to improving patient safety. Staff shortages, and poor education and training were cited as factors contributing to MEs as well as barriers emphasizing the need for addressing workforce development and maintaining mandatory staff-to-patient ratios. The findings emphasise further study of an educational needs assessment for improving patient safety and enforcement of legible or printed medical orders by generic names immediately to improve medication safety. Establishing greater open communication between healthcare providers, process changes, developing standard protocols, and creation of a nonpunitive culture of safety are other priority areas with a corresponding change in organizational culture. Use of information technology and computers would have a major positive impact on patient safety, sparing more time for patient care activities. Accreditation can also serve as a driver for improving quality of care.
Footnotes
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Conflict of interest statement: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Contributor Information
Sangeeta Sharma, Institute of Human Behaviour and Allied Sciences, Shahdara, Delhi 110095, India.
Fauzia Tabassum, Institute of Human Behaviour and Allied Sciences, Shahdara, Delhi, India.
Sarbjeet Khurana, Institute of Human Behaviour and Allied Sciences, Shahdara, Delhi, India.
Kaveri Kapoor, Institute of Human Behaviour and Allied Sciences, Shahdara, Delhi, India.
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