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概要

Medical Errors: The Need for Institutional Change to Ensure Patient’s Safety

Naima Rasool*, Mohammad Nabeel Mustafa

Background: Medical Errors (ME) are the preventable adverse effects of medical care, resulting in numerous deaths annually worldwide. In Pakistan situation is more complex, due to overly populated hospitals, fewer underpaid overworked doctors and paramedics, no policy to deal with the subject, and seldom any checks and balances. This study is an effort to sensitize and equip our surgical trainees and paramedical staff to recognize and deal with medical errors which along with the help of institutional management, will bring a positive change in the clinical setting to decrease the incidence of errors while ensuring patients safety.

Methodology: A structured Pre-workshop questionnaire was given to the participants to fill out; it was followed by a PowerPoint presentation along with a discussion. A 12 mins long teaching video from the Center of Bioethics and Culture (CBEC) archive was shown, which was followed by an interactive discussion. Participants were asked to evaluate the Workshop on a structured Performa. A Post-workshop survey was done after 04 weeks to assess the impact of the activity in the clinical settings of the participants. Data were analyzed by qualitative and quantitative methods. For the quantitative part, emerging themes were analyzed using NVivo software.

Results: There were 21 participants from the National Institute of Child Health, Karachi (13 paramedics/08 doctors) while 16 were from Fazaya Ruth Pfau Medical College, Karachi (02 paramedics, 14 doctors). The preliminary coding after the clustering of verbatims was developed. A total of 03 main themes emerged, based on participants’ knowledge, causes/contributing factors, and ethical implications of medical errors.

1-In the theme of knowledge, the sub-themes that emerged were, “wrong medication and wrong diagnosis”.

2-In the theme of causes and contributing factors, participants used the verbatims of "commonest error is Senior doctor's behavior and is their responsibility " behavior and responsibility, lack of knowledge and shortage of staff”.

3-In ethical implication, “burnout due to stress” was the commonest sub-theme.

After 04 weeks, participants were asked about steps taken to reduce the error events. The responses were grouped under the “need for administration’s cooperation, SOPs following, and documentation” codes.

Recommendations: Training, sensitization and realization of the problems related to medical error are the need of the hour.

The change at the institutional level is the key to curbing the problem.