Studying Medical Errors among Hospital-Staff at Saudi Health Providers

D

Journal of Materials Science and Engineering A 2 (1) (2012) 41-52

DAVID

PUBLISHING

Studying Medical Errors among Hospital-Staff at Saudi Health Providers Khalid Saad Al-Saleh and Mohamed Zaki Ramadan Department Industrial Engineering, King Saud University, Riyadh, Riyadh 11421, Saudi Arabia Received: February 23, 2011 / Accepted: March 22, 2011 / Published: January 10, 2012. Abstract: To answer several raised issues among Saudi health providers related to medical errors. A questionnaire, containing 50 questions about what medical staffs feel are the biggest contributors to medical errors, their attitudes regarding compliance with the national safety standards goals and suggestions for improving the system, was aimed at medical members dealing directly with the patients to identify the reasons of causing, avoiding, and preventing medical errors. The results of 932 responses indicated that heavy workload and lack of education/experience were significantly higher among other reasons of having medical errors. Well education and continuous training, change in work schedule in such a way of less length of time on night shift, and less working hours throughout the week significantly affect reduction of medical errors in terms of human factors measures. No correlation was found between medical errors reporting and offering training programs in medical errors reporting. However, hospitals that offered and encouraged their medical staffs to have training programs and up-to date workshops related to their specialties decreased their errors significantly when compared to the hospitals that did not offer nor encourage their employees to have such types of training programs (p < 0.012). This paper provides guidelines to reduce and to eliminate the medical errors which occurred in hospitals located at north, middle, and south of Saudi Arabia. Key words: Medical errors, adverse events, hospital care, human factors.

1. Introduction Patient safety is a critical component of healthcare quality. As healthcare organizations continually strive in order to have significant improvement, there is a growing recognition of the importance of establishing a culture of patient safety. Medical errors are a leading cause of death and kill some of 44,000 people in U.S. hospitals each year and that number may reach much higher, at 98,000 [1, 2]. Even using the lower estimate, more people die from medical mistakes each year than from highway accidents, breast cancer, or AIDS. Also, deaths from medication errors that take place both in and out of hospitals are more than 7,000 annually. These medical errors cost the American economy as much as $29 billion each year [2]. Additional studies in Corresponding author: Khalid Saad Al-Saleh, assistant professor, research fields: human factors, ergonomics, safety, manual work, technology transfer. E-mail: [email protected].

Australia [3], Canada [4] and New Zealand [5] have established that the rates of adverse events did not significantly differ among these countries and those cited in the United States [6]. Another study showed that medical errors are the third leading cause of death in the United States. This study apparently shows that there were 2,000 deaths/year from unnecessary surgery; 7,000 deaths/year from medication errors in hospitals; 20,000 deaths/year from other errors in hospitals; 80,000 deaths/year from infections in hospitals; 106,000 deaths/year from non-error, adverse effects of medications [7]. In Saudi Arabia, 40,000 medical errors complaints are filed yearly, a third of medical practitioners are banned from travel due to those complaints, and 80% of those complaints end without convection. Furthermore, most of the procedures carried out at the hospitals prior to any medical intervention are not known to the patients [8].

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Studying Medical Errors among Hospital-Staff at Saudi Health Providers

Research shows that most medical errors are largely preventable [9]. In this context, Harvard University conducted a landmark study on medical errors, which led to the recognition that engineers specializing in human factors and health systems are needed to improve the existing system [10]. Recently, the medical error taxonomies were examined and varied in terms of domain-specificity, granularity, and developmental process [11]. In their study, they describe 26 medical error taxonomies using a human factors perspective. Even those medical error taxonomies provide different information; these differences affect medical error management needs to be investigated. Cacciabue and Vella [12] argued that human factors considerations should be included in the design and safety assessment processes of socio-technical systems. In addition, human errors must be considered as an intrinsic component of any socio-technical system. Rivera and Karsh [13] pointed out that an understanding of the human factors and systems engineering to solve patient safety problems are lacking, and confusion remains about what it means to apply their principles. Therefore, patient safety is the number one goal of every health care organization. Building a safer health care system requires research that identifies system factors that contribute to medical errors. Conducting research which establishes factors that medical staffs identify and describing medical errors will provide a foundation for process and system improvements to reduce errors. The research question will guide the proposed research which is, “What are medical staffs’ perceptions of the factors that contribute to medical errors in Saudi healthcare setting?” The purpose of this research study is to identify, describe, and resolve medical staffs’ perception of factors that contribute to medical errors in Saudi health care setting.

2. Methods Medical staffs in many Saudi hospitals were sought out to help identify the problems and solutions for medical errors from their viewpoint and from a

system’s perspective. This research survey instrument questioned medical staff participants about medical errors education, awareness and reporting habits for medical errors in different departments among most of Saudi hospitals. The questionnaire was designed and aimed at medical members dealing directly with the patients. The questionnaire contained 50 questions about what medical staffs feel are the biggest contributors to medical errors, their attitudes regarding compliance with

the national

safety standards goals

and

suggestions for improving the system. Demographic questions were included for the purpose of data analysis. The study was designed to evaluate the relationship between sleep deprivation, performance, and the number of occupational errors and patient errors, and to measure systemic and individual factors that contribute to medical errors and compliance rates at different hospitals [14, 15]. A multi-variable tool was surveyed and asked medical staffs to report their experiences with medical errors that have been made in their clinical settings. Members of the medical staff were asked to describe how they have made decisions about reporting those errors. The sample size was calculated to assess the adequacy of the total sample needed using Comrey and Lee’s [16] guidelines for the design analysis of (i.e., 5 responses/questionnaire item X 50 questions in the questionnaire) 250 responses as good, 500 responses as very good. The sample size target was a minimum of 250 completed surveys to support the data analysis. Using a minimum sample size ensures statistical power for the design analysis for the study [16-20]. The participants in this study were all clinical staffs employed at the study site. Hospitals in the kingdom of Saudi Arabia were selected as the study population because they are the bedside providers who administer care to the patients. Although recruitment efforts for the survey were concentrated on five target locations (i.e., north, south, east, west, and middle territories of

Studying Medical Errors among Hospital-Staff at Saudi Health Providers

the Kingdom), questionnaires were received only from three different areas where east and west areas refused to participate in such type of survey. Therefore, middle, north, and south territories are referred to be as hospital territories A, B and C, respectively. While there is evidence that night-shift workers are not the only workers that are sleep deprived [21], there is also evidence that night-shift workers experience poorer quality and shorter duration of sleep than their dayshift counterparts [22]. Therefore medical staffs who are employed full-time and who work the night shifts in a hospital setting were included to participate in this study. The hospital setting was determined to be important because of the need to have a high level of psychomotor performance in order to accomplish caring duties [23, 24]. Shift lengths of 8, 10, and 12 h were selected because there is evidence that the length of shift may influence the duration of sleep [25]. To explore the relationships between shift work (predictor variable), sleepiness and accidents, univariate methods were used [26]. Other covariates included fatigue, quality of sleep, nodding off while driving to or from work, and medication errors [26]. Convenience sampling was used to obtain the sample size, and potential sampling bias was identified [27]. Inclusion criteria included licensed medical staffs who work a full-time night shift in the hospital. Since there is evidence that years of experience influence the occurrence of errors and that sleep deprivation can be cumulative, medical staffs that have at least one year of experience working in the hospital were included [22, 26]. Men and women participants from the ages of 21-65 years who varied in ethnic background were included in the study [26]. The survey instrument was adopted from four researches [28-31]. The survey consisted of 4 sections namely A, B, C, and D. In section A, the survey included personal demographic information such as age, ethnic background, gender, marital status, other individuals to help in the home, dependents in the home, age of dependents, highest level of staff’s

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education, years of experience, employment status (full time or part time), number of hours per shift, hours worked per week, length of time on night shift, untreated sleep disorders, diagnosed metabolic diseases, hours slept in the last 24 h, hours worked in the past two days, number of patient related errors and description of the error, and number and description of occupational related errors. In section B, the survey included whether or not the medical staff had ever attended educational sessions about recognizing or reporting medical error. While in section C, the survey included: if the medical staff could recall if error disclosure was discussed in medical setting orientation; questions about the internal culture of the work environment and reporting policies of various departments. In section D, the survey included: the number of medical error reports made by the medical personnel in the past; how and to whom those errors were reported; the reasons for reporting or for failure to report; attitudes about potential interventions for increasing error reports; and medical staffs’ recommendations for reducing medical errors or increasing compliance. Patient care errors were measured with items 1 through 10 on D section of the questionnaire. A patient related error referred to any accident or injury to the patient, any omitted treatment, medication error, near medication error, errors in transmission of doctors’ orders, errors in documentation, adverse drug event, improper transfusion techniques, falls, bums, pressure ulcers, mistaken identity, failure to change a dressing, missed treatments, or missed medication, and omission of an intervention that is needed [32, 33]. The entire questionnaire required 10-15 minutes to be completed. Data was collected in a confidential manner with no individual identifiers other than hospital and territory of residence, and results were reported only in aggregate. Descriptive statistics included frequencies, percentages, means, and standard deviations. Inferential analysis included k-independent samples t-tests and non-parametric tests. The significant level

44

Studying Medical Errors among Hospital-Staff at Saudi Health Providers

used for the inferential statistics was 0.05.

3. Results 3.1 Results of the Study Description Of the 2000 survey questionnaires that were handled, delivered, or mailed to the hospitals administrations, 932 (46.6%) were completed and returned. Of those returned, 421 were from territory A, 273 were from territory B, and 238 were from territory C of the Kingdom. A summary of the medical staffs’ demographic data is shown in Table 1. From territory A, four hospitals participated in the study, with 26 (6.2%) of the sample obtained from hospital one, 176 (41.8%) obtained from hospital two, 129 (30.6%) of the sample obtained from hospital three, and 90 (21.4%) of the sample obtained from hospital four. From territory B, five hospitals participated in the study, with 94 (34.4%) of the sample obtained from hospital one, 25 (9.2%) obtained from hospital two, 63 (23.1%) of the sample obtained from hospital three, 44 (16.1%) of the sample obtained from hospital four, and 47 (17.2%) of the sample obtained from hospital five. From territory C, seven hospitals participated in the study, with 23 (9.7%) of the sample obtained from hospital one, 59 (24.8%) obtained from hospital two, 43 (18.1%) of the sample obtained from hospital three, 52 (21.8%) of the sample obtained from hospital four, 25 (10.4%) of the sample obtained from hospital five, 13 (5.5%) of the sample obtained from hospital six, and 23 (9.7%) of the sample obtained from hospital seven. The mean age of the study respondents was 36 years, with a range from 20 years to 64 years. 461 (49.5%) of the respondents were women and 463 (49.7%) were men. Eight responses out of 932 were identified neither man nor woman. 82 had sleep deviation disorders where 22 had treated this disorder effectively; however, only 25 have had this disorder untreated so far. The mean year of medical experience for all respondents was 7.3 years.

Table 1 Summary of the medical staffs’ demographic data. Variable Gender Male Female Degree High school Diploma Bachelors Masters

Frequency (%) 463 (49.7) 461 (49.5) 24 (2.6) 387 (41.5) 330 (35.4) 109 (11.70) 69 (7.4)

Ph.D. Hospital & territory Hospital 1A Hospital 2A Hospital 3A Hospital 4A Hospital 1B Hospital 2B Hospital 3B Hospital 4B Hospital 5B Hospital 1C Hospital 2C Hospital 3C Hospital 4C Hospital 5C Hospital 6C Hospital 7C Marital Status: Married Not married

631 (67.7) 259 (27.8)

Caring for an aged parent Yes No

201 (22.5) 694 (77.5)

26 (2.8) 176 (18.88) 129 (13.84) 90 (9.66) 94 (10.09) 25 (2.68) 63 (6.76) 44 (4.72) 47 (5.04) 23 (2.47) 59 (6.33) 43 (4.61) 52 (5.58) 25 (2.68) 13 (1.39) 23 (2.47)

Rotate shift Yes 506 (55.3) 409 (44.7) No Difficulty staying awake while at Yesk 108 (11.8) No 803 (88.2)

3.2 Results of Medical Staff Demographic Data Four-hundred and eleven (44.1%) of the samples had associate middle degrees in medical schools, 330 (35.4%) had bachelors’ degrees, and 177 (19%) had higher education in medicine. 414 of the medical staffs (44.4%) worked 5 or fewer years in their units. 470 of the sample (50.4%) worked more than five years on the

Studying Medical Errors among Hospital-Staff at Saudi Health Providers

unit, and 460 (49.4%) of the medical personnel worked the night shift more than five years. The sample consisted of 631 (67.7%) married, 200 (21.5%) caring for aged parents in the home, 56 (6%) caring for a sick child or other sick adult in the home. The difference between the total answered and the presented sample size is due to missing values. When asked the question of whether or not the medical staff had ever had formal education and training regarding the reporting of medical errors, 230 (24.7%) said yes, 615 (66%) said no, 59 (6.3%) could not remember, and 28 (3%) did not respond to the question. For those who answered yes, 25 (10.9%) stated that training had occurred only in their education, 112 (48.7%) stated that training had occurred only in the hospital setting, and 87 (37.8%) stated that they had received training in both school and again in the hospital setting. Only 6 (2.6%) respondents who indicated they had received some training answered that this training had been in an alternative setting, citing this as an external continuing education setting. Additional comments written in this section indicated that few of the hospital trainings regarding error reporting were described as “online” computerized training. This research tested the hypothesis of the increase in reporting of medical errors due to the provisions of training programs and workshops by hospitals. It was hypothesized that the number of reported medical errors in the hospitals which provided training programs and workshops about reporting medical errors will be higher than the number of medical errors reported in hospitals which did not provide training programs and workshops about reporting medical errors. Result of testing this hypothesis showed that there were no statistically significant differences in medical errors reporting whether the hospitals offered such types of training programs or not. However, hospitals that offered and encouraged their medical staffs to have training programs and up-to date workshops related to their specialities (Mean errors rate/physician = 1.13, SD = 0.37) decreased their errors

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significantly when compared to the hospitals that did not offer nor encourage their employees to have such types of training programs (Mean errors rate/physician = 1.33, SD = 0.98; p < 0.012). Medical staffs were next asked if they had received any education and training regarding ethical decision making. 267 (28.6%) indicated that they had participated in this type of training, 538 (57.8%) said they had not, 74 (7.9%) could not remember if they had or had not attended this type of training, 53 respondents (5.7%) did not answer the question. The medical staffs indicated that this training had taken place in the following manner: 42 (15.7%) reported training in undergraduate school only; 51 (19.1%) reported training in graduate school only; 123 (46.1%) reported training in hospital setting only; 2 (0.8%) reported training in both undergraduate and graduate school; 14 (5.2%) reported training in three venues, undergraduate, graduate and hospital education; 20 (7.5%) reported training in graduate and hospital training; 15 (5.6%) reported training in “other”, indicating external continuing education as the source. Testing the differences in age groups in years of medical staffs had no effect on medical errors. The results of the non-parametric test showed that age groups in years of medical experience had no statistically significant effect on medical errors. 3.3 Results of Medical Staff Opinions Regarding Medical Errors The study subjects were asked several opinion questions regarding medical errors in their units. The first asked if the medical staff felt that she/he was provided with adequate resources when faced with the decision to report a medical error. 476 (51%) responded yes, 403 (43.3%) responded no, and 53 respondent (5.7%) did not answer the question. Next, the subject was asked whether she/he felt supported by certain other professional colleagues and administrators when faced with reporting a medical error. The majority 580 (62.2%) felt that they had at

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Studying Medical Errors among Hospital-Staff at Saudi Health Providers

least some support when faced with this situation. Most medical staffs 540 (93.1%) indicated support from a combination of colleagues, supervisors, and physician colleagues. Only 40 (6.9%) reported that they felt supported by hospital administration when reporting a medical error. 183 (19.6%) reported that they have not felt supported at all when faced with the decision to report a medical error. Medical staffs were next asked to indicate whether or not they felt that they had been provided with adequate information and training regarding the reporting of medical errors in their current clinical setting. 353 respondents (37.9%) said yes, 510 (54.7%) said no, and 69 (7.4%) did not answer the question. When asked what the medical staff thought was the most common medical error made in the clinical department where they worked, they checked several areas. Equipment failure was cited by 244 (26.2%) of the respondents as being the most common error. Many 152 (16.3%) felt that medication errors were the second most common. Omission of a diagnostic test or procedure was an area cited as being the third most common source of error 112 (12%); 23 (2.5%) cited procedure error. 190 (20.4%) of respondents added their own written concerns about common medical errors, which included confusion regarding verbal orders (3 cases), “over—testing” (2 cases), failure of patient to be returned to monitoring status following diagnostic testing outside of department (case), “holding” admitted patients (case), mislabeling of specimens (5 cases), and “duplicate dosing of a medication to the same patient” (2 cases). 211 (22.6%) respondent did not answer the question, but indicated that s/he did not feel there were many errors made in their departments. The next question asked for an opinion about whether the nurse felt that guidelines were followed consistently in their institution regarding medical errors. 413 (44.3%) responded yes, 409 (43.9%) responded no, 107 (11.5%) did not answer the question and 3 (0.3%) stated they were unsure about the practice

of others. The final question in this section asked whether the nurse felt that the issues involved in reporting errors are different from one medical person than they are for physicians. The overwhelming majority, 539 (57.8%) said yes, 211 (22.6%) said no, 12 (1.3%) said they were unsure of physician practices in their hospitals and 170 (18.3%) did not answer the question. 3.4 Results of Past Experience, Reason, Attitude, and Influence of Medical Errors The study subjects also completed a series of questions asking them about actual past experiences with medical errors. The most common response (484 or 51.9%) indicated that they had never made a medical error. The next most common answer (118 respondents or 12.7%) was that they had been “disciplined by a supervisor” (for example, “written up”). Respondents next most commonly (93 or 9.9%) indicated that “nothing” happened when they had reported an error. 20 respondents (2.1%) was that they had been “required to take an educational class”. 13 respondents (1.5%) had been noted in their annual performance evaluations. Only 17 (1.8%) respondents had been disciplined by a higher board. 16 (1.7%) respondents were disciplined by a supervisor and were asked to take educational classes. 15 (1.6%) respondents were disciplined by a supervisor and were noted in their annual performance evaluations. 11 (1.2%) respondents were disciplined by both supervisor and by a higher board. 9 (1%) respondents were disciplined by a supervisor, noted in their annual performance evaluations, and were required to take an educational classes. 136 (14.6%) did not answer the question. To test the relationship between medical errors and territories locations, a Kruskal-Wallis test was performed and showed that there were significant differences in medical errors among the three territories locations (χ2 (2) = 9.308, p < 0.01). Territory #C had higher average/physician medical errors (1.40) when compared to territory #A (1.15) based on

Studying Medical Errors among Hospital-Staff at Saudi Health Providers

Mann-Whitney test (Z = -3.08, p < 0.002). All contributing factors were tested in each territory to pinpoint the factors leading in committing errors. In territory #A, Inexperience or lack of education, inadequate technology, lack of vigilance, fatigue, and lack of adherence to medical administrations’ policies were positively associated with medical errors (all at p < 0.05). In territory #B, lack of vigilance, fatigue, heavy load (number of patients, high acuity patients), time constraints, and distractions (interruptions from visitors, phone cells, MDs) were positively associated with medical errors (all at p < 0.05). In territory #C, inexperience or lack of education, inadequate technology, fatigue, heavy load (number of patients, high acuity patients), time constraints, staffing issues (unavailability of care partners, ward clerks), distractions (interruptions from visitors, phone cells, MDs) were positively associated with medical errors (all at p < 0.001). Medical staffs were questioned about the circumstances that under which they would report a medical error. One hundred-eighty (19.3%) wrote in that they would always report an error, regardless of who made it or what the circumstances were. 218 (23.4%) might not report if there was no harm to the patient and the error was recognized quickly; 317 (34%) might not report the error if it was recognized quickly; 45 (4.8%) might not report if another medical staff told them not to report, a physician told them not to report, or their supervisor told them not to report; and 172 (18.5%) did not answer the question. Interestingly, in the next question, most (660 or 70.8%) of the study subjects reported that they would always report an error that resulted in harm to a patient; 76 or 8.1% respondents answered that they would only report if the error was made by a novice nurse. One hundred forty-seven or 15.7% reported that in addition to reporting if there was harm to a patient, they would also report any error made by a novice nurse. Forty-nine (5.4%) did not respond to this question. The final four questions addressed whether or not the

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medical staff had ever not reported an error, or had asked a provider to change an order because of an error that was made. The medical member was also asked about personal feelings regarding the reporting of errors. Seventy-two (7.7%) of the study subjects answered that they had made a medical error that they had never reported. Seven-hundred and eighty-five (84.3%) answered that they had not made a clinical error and subsequently not reported it. Seventy-five (8%) subjects did not answer the question. Out of the seventy-two who made medical errors and not reported last year, 34 (47.2%) respondents made only one error; 16 (22.2%) respondents made two errors; 4 (5.5%) respondents made three errors; one respondent (1.4%) made 4 errors, another one (1.4%) made 5 errors. Two respondents (2.8%) made more than 10 errors each. The rest of the respondents (19.5%) did not answer this question. One-hundred and sixty-eight participants (18%) had asked a physician or extender to change an order (for a medication or procedure) to match something that had already been delivered, though several added written comments that they had asked for the order to be changed to correct an error made by the physician or extender, not to reflect an error made by the nurse. One nurse wrote a comment indicating that she had been asked to “cover” for a physician who had made a medical error, and that she had also often had to intervene when a physician wrote for an incorrect medication order. Six-hundred and fifty-seven (70.5%) said they had not asked to have an order changed. One hundred and seven (11.5%) did not respond to this question. When asked if they had ever been afraid to report a medical error that they had made, 84 (9%) said yes, 754 (80.9%) said no, and 94 (10.1%) did not answer the question. While someone else had made, 129 (13.9%) said yes, 717 (77%) said no, and 86 (9.1%) did not answer the question. When asked if they had any accident or injury while working on their shifts through last year, 112 (12%) said yes, 751 (80.6%) said no, and

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Studying Medical Errors among Hospital-Staff at Saudi Health Providers

69 (7.4%) did not answer the question. The results related to the eight contributing factors are shown in Table 2. These contributing factors include systems-based problems such as heavy workloads, lack of education, time constraints, distractions, fatigue, and inadequate coordination of resources, all of which form the milieu for compliance. Men participants significantly ranked more than women participants in “inexperience/lack of education”, “lack of vigilance”, and “fatigue” as contributing factors for making medical errors. In addition, all participants high significantly ranked that “heavy workload” and “inexperience/lack of education” are the most contributing factors for doing medical errors when compared to the other contributing factors. Overall, it was found that these current workplace constraints contribute to medical errors by creating sub-optimal circumstances for medical staffs to accurately follow safety measures, thus predisposing them to making errors. What recommendations do medical staffs have for reducing medical errors or increasing compliance? As shown in Table 3, men participants more significantly Table 2

ranked “reminder to check patient” as one of the potential solutions when compared to women participants. However, women participants more significantly ranked “technology needed such as bar code” as one of the potential solutions when compared to men participants. Finally, “direct observation/Audits”, “reminder to check patient”, and “Well stocked medication-dispensing machine” are the most effective potential solutions for reducing medical errors. In addition, potential solutions included better coordinated providers, educational interventions and reminders to foster a culture of safety.

4. Discussion This research’s focus was on medical errors made in the hospital settings. While it is easy to say that accurately followed protocols would eliminate errors, the answer is just not that simple. From the results of the study, medical staffs are inundated and pulled in multiple directions. Any well-intended healthcare worker placed in a similar situation would be subjected to the same struggle to juggle tasks procedures and policies, some of which are constantly changing.

Contributing factors.

Contributing problems Heavy workload

Female mean weight (ranking) 4.084 (1) t = 0.536, p = 0.592

Inexperience/lack of education

3.815 (3)

Male mean weight Total mean weight (ranking) (ranking) 4.048 (1) 4.066 (1) * 4.129 (2)

t = -4.375, p < 0.001 Distractions staffing issues

3.818 (2)

Lack of vigilance

3.641 (4)

3.820 (3) t = -0.034, p = 0.972 3.790 (4) t = -1.99, p < 0.047

Inadequate of technology

3.639 (5)

3.714 (5) t = -1.093, p < 0.275

Fatigue

3.541 (8)

3.739 (6) t = -2.613, p < 0.009

Staffing issues

3.550 (7)

3.595 (7) t = -0.644, p = 0.52

Time constraints

3.610 (6)

3.473 (8) t = 1.896, p =0.058

* p < 0.0001.

3.975 (2) * 3.819 (3) 3.719 (4) 3.677 (5) 3.643 (6) 3.573 (7) 3.538 (8)

Studying Medical Errors among Hospital-Staff at Saudi Health Providers

Table 3

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Potential solutions.

Potential solutions Direct observation/audits Reminder to check patient Well stocked machine

Female 4.200 (1)

Male 4.172 (1) t = 0.547, p < 0.585

4.182 (2)

4.026 (3) t = 2.82, p < 0.005

medication-dispensing 4.081 (3)

Faster order processing time

4.107 (2) t = -0.532, p = 0.595

4.000 (4)

3.922 (6) t = 1.384, p = 0.167

Standardized hand-off report time-outs Technology

3.938 (5)

3.940 (5) t = -0.033, p = 0.974

3.829 (7)

Time-outs during medical preparation and 3.863 (6) administration.

3.954 (4) t = -2.218, p < 0.027 3.826 (7) t = 0.622, p = 0.534

Total 4.185 (1) * 4.108 (2) * 4.095 (3) * 3.960 (4) 3.938 (5) 3.896 (6) 3.840 (7)

* p < 0.0001.

A minefield filled with constant interruptions, distractions and timed tasks is not an optimal environment for anyone. The solution then, is to develop good habits and safe best practices while providing an environment that enables adherence to safety policies. The question is how do we maintain best practices in a chaotic environment? To understand the results from this research, it was discussed in the context of system factors and human factors. System factors affect human behaviours, impairing even the best people to function at their optimal level. The systemic problems identified in this research (workload pressures, time constraints, distractions) are not unique to the medical staffs. In fact, it was not very surprising that medical staffs listed those items as the highest obstacles to an error free workplace. Environmental factors (distractions, interruptions) and human factors (stress, fatigue, and noncompliance) have been documented and confirmed as contributors to medical errors [34, 35]. Another recent study further demonstrated that work-related stress is a positive predictor for compromising patient safety [36]. What is unique about this research is the engagement and recognition of the medical staffs’ perspectives in solving a problem. This research delved into the underlying reasons noncompliance, viewing the problem from both the individual’s perspectives as

well as from the standpoint of the system. As there are few studies examining the attitudes and perspectives of medical staffs when it comes to patient safety, the results from this research should help us understand how medical members see the problems and how we enlist them in developing the solutions. Most policies come from a top-down mandate, which in a complex system such as hospital settings, are sometimes necessary to maintain order. However, the problems that imposed mandates are that the people who must adhere to the policy are also distanced from the origins of the policy. Even though the policy sets standards for best policies, by the time it reaches busy medical provider, it just becomes another added procedure to their never-ending list of things to do. Thus, a full compliance is not achieved and errors occur. Medical staffs in this research urged the administrations to view medical errors as system’s problem, not as an individual compliance problem. One major challenge in a chaotic work environment is in prioritizing tasks amidst time constraints. Unfortunately, medical staff shortages and limited resources curb the ability of the providers to delegate tasks to others. This is an ongoing problem that all hospital administrators will have to address in their budget and hiring process. For example, the nursing shortage is a national problem. So is the need for allied

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Studying Medical Errors among Hospital-Staff at Saudi Health Providers

health providers such as care partners and medical clerks. At what point do we outweigh the cost of adverse events, and possibly even lives, from overworked and overwhelmed nurses against the cost of additional staff? This system’s issue is one that would probably not disappear easily when nurses ultimately have the responsibility to prioritized patient safety in the time and work constraints imposed by the system. Clearly, there are other factors involved, as illustrated by the findings, the lack of interconnectivity between the various healthcare providers also poses confounders in the medical staffs’ abilities to prioritize and delegate. There are two issues relating to the problem of segregated systems. The lack of technical connections between nursing, pharmacy, and physician data input is a technology and programming issue. The second is the lack of communication and coordination among the healthcare providers. In fact, those problems can be addressed through information-sharing and team-training, dialogue and education. In addition, hospitals that offered and encouraged their medical staffs to have training programs and up-to date workshops related to their specialities decreased their errors significantly when compared to the hospitals that did not offer nor encourage their employees to have such types of training programs. This result agreed with the results of other studies [37, 38]. The human factors contributing to medical errors include fatigue, stress, noncompliance and education. As mentioned earlier, fatigue and stress stem from systemic factors. In this research, about 75% of the medical staffs ranked fatigue as a contributor to errors. Rogers et al. [33] found that nurses who worked 12 hours or more hours in a shift were three times more likely to make errors, a significant increase over those who worked 8.5 h or less. Physical strain has led to increased job dissatisfaction and absenteeism, as well as higher turnover rates. The contribution of stress and fatigue,

along with increased workloads, challenge medical staffs’ vigilance and make them dangerous sparks fuelled by poor behaviour, with patients’ ultimately taking on their risks. Administrations and policy makers should adequately address the problems of physiological strain. On the other hand, Fogarty and McKeon [39] reported that in a structure equation model of organizational and individual variables, the only direct contribution to medical errors was compliance violations. While many of the other systemic factors increase the risk for making mistakes, not following safety standards appeared to be the biggest direct instigators mistakes. With the limited working times when they are overwhelmed, fatigue, stress, and the noncompliance is becoming more even higher rate.

5. Conclusions The importance of preventing medical errors educational programs were not being stressed enough. Medical Staffs admit that they know the safety policies; yet, they have trouble complying with them. Tolerance and silence cultivate negative behaviours and create a culture of lower expectations. Overconfidence and tolerance for poor behaviours are culprits in this fight against awareness and vigilance. The addition of work stress and systemic problems are disempowering to medical staffs, as now their attention is spread thin across a multitude of tasks and timelines. If medical staffs do not individually embrace the concept that shortcuts lead to increased risks for patients, then no matter which systemic problems are resolved, such as reduction in work hours or number of patients, a lax attitude will translate into poor habits. For example, technology may solve one problem, but often leads to other problems. At some hospitals, despite the implementation of barcode, nurses were still not complaint in safety policies and were discovering ways to work around the safety protocol of bar code scanning, ultimately putting patients at risk [40]. In fact, the bottom line is to build good safety habits.

Studying Medical Errors among Hospital-Staff at Saudi Health Providers

Finally, educating and empowering the medical staffs, and cultivating a culture of safety for both health providers and patients are the main tools that will hopefully apply in the hospital settings to enable more efficient systems.

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Acknowledgments

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The authors wish to thank the participants who made this work possible. This work was supported by King Abdulaziz City for Science and Technology (KACST) [Grant # AT 26-39].

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