Table 2.

Patient safety issues and concerns

Themes	Participant statements
Medication/drug errors	‘I think the most common is errors in drug doses and medications. […] medication error includes errors in giving IV fluids like sometimes wrong IV fluids, wrong rate of administration—improper calculation of the drop rates’ (Medical doctor).’ ‘[…] misuse of antibiotics—sometimes you continue antibiotics even for cough and cold where it is not required. They [doctors] use high dosage of different antibiotics for organisms that are not sensitive.’ (Medical doctor)
Healthcare-associated infections	‘Infection is definitely an issue. Previously where I used to work, […] in a small district hospital, usually patient with small surgery—minor surgery was getting post-surgery wound infection. Wound not healing faster.’ (Senior manager) ‘We do come across hospital acquired infections—people especially with long term hospitalisation tend to get urinary tract infections. I don’t know how people [healthcare providers] are handling the catheterisation process.’ (Medical doctor)
Surgical errors and postoperative complications	‘We always hear from the operation theatre that some gauze pieces or some instrument has been left inside.’ (Nurse)
Diagnostic errors	‘They [doctors] misdiagnose and then sometimes they give wrong medication which I have seen in one case that the patient really had adverse effect.’ (Nurse)
Laboratory/blood testing errors	‘Sometimes there are few laboratory mistakes. I don’t know whether it is the printing mistakes, sometimes we send two samples almost within 2 to 3 hours gap and the report come completely different. Maybe because staff are giving wrong sample for the other patient or is the printing mistake from the lab […]. We have cases like same patient having done the same investigations in few hours showed vast difference in the reading.’ (Nurse)
Fall injuries	‘While patient is transferred in the trolley there was one incident where the patient went off the trolley. And then few times we have heard patient falling from the bed. So fall is common.’ (Ward manager)
Communication errors	‘Most of the time the misunderstanding that happens between the patient and the staff is due to lack of adequate communication. Many a times what we have done is for example probably not spend enough time on that part—explaining the diagnosis, where is the problem, what medicine you are prescribing, how you need to take that medicine, what are the side effects of the medicines, all these things, you know.’ (Senior manager—NGM1) ‘I think one complaint we hear is that of verbal abuse by the health professionals to patients and their relatives.’ (Senior manager)
Patient identification errors	‘I think one pertinent one is for lack of patient identification marks. Our Bhutanese have similar names and then that can lead to, during procedures in rush hours, doing procedures in a wrong patient.’ (Medical doctor)