Patient Safety Full Report

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

people in your network
who might find it relevant
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: hnabudere@gmail.com
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 Commissions 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 EvidenceInformed Policy Network (EVIPNet) in
Africa and the Regional East African
Community Health (REACH) Policy
Initiative. SURE is funded by the European
Commissions 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 evidenceinformed 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
Table of Contents
PREFACE
ONE-PAGE SUMMARY
THE PROBLEM
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.
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.
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.
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
o
o
o
o
Community sensitization and mobilisation to improve knowledge, skills, attitudes, and

motivation of health consumers, and other stakeholders
Training of allied health professionals to perform drug re-assessments at lower level
health facilities where there are no allocations for clinical pharmacists positions.
Continuing professional education, outreach visits, audit and feedback to motivate
physician prescribers in adopting medication review.
Adequate remuneration, material and non-material incentives are to motivate health
workers, particularly for hard-to-reach areas.
The current tax-based financing could be expanded with social health insurance and
voluntary schemes such as community/cooperative-based health insurance and privatefor-profit health insurance covering particular populations to scale up the proposed
policy options.
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 1950s 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)
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
Service Delivery
Patient Safety Action areas

Health care-associated infections
Related Millennium
Development Goals
MDG 4 Child mortality MDG 5
Maternal health MDG 6
Communicable diseases
Safe surgical care

Maternal health
Medication safety

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
Leadership / Governance
Health systems services and

patient safety
Develop and implement national

policy for patient safety
MDG 8 Partnership development
Knowledge and learning in patient

safety
Awareness raising for patient
safety
Partnerships for patient safety
10
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)
11
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)
12
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 dIvoire and Ghana compared different types of
injection devices for HIV and Hepatitis B transmission between patient-to-patient, patientto-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
Resterilizable N&S
HBV
HIV
Patient-to-Health
care worker
transmission
HBV
HIV
8100
81
1350
14
Patient-toCommunity
transmission
HBV
HIV
<1
<1
All Routes totals
HBV
HIV
Both
9450
95
9545
13
Disposable N&S
8100
Reusable-nozzle jet
270
injector
Auto-shielding N&S
0
Disposable0
cartridge jet injector
N&S = Needle and Syringe
Source: Ekwueme et al., 2002 (33)
81
810
<1
8913
89
9002
270
273
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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)
Injections
Uganda (2004/2005)
8.2%
Kenya (2003)
Tanzania (2003/2004)
5.2%
11.1%
Men (15-49 years)
Knows to avoid HIV infection by avoiding:

Blood
Injections
Blood
Transfusions
Transfusions
2.6%
9.3%
5.5%
5.0%
4.6%
4.8%
14.1%
6.8%
5.5%
Source: DHS/AIS 2003-2006
Table 4: HIV Prevalence by Receipt of more than 3 Medical Injections in Recent Past
Country/Year
Women (15-49 years)
Men (15-49 years)
Uganda (2004/2005)
Yes
10.2%
No
6.1%
p-value
0.000
Yes
8.5%
No
3.9%
p-value
0.000
Ethiopia (2005)
Zimbabwe (2006)
3.2%
33.9%
1.6%
20.8%
0.004
0.000
1.4%
36.0%
0.9%
14.1%
0.247
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)
14
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

Country/Year
Women (15-49 years)
Men (15-49 years)
Uganda (2004/2005)
Yes
10.2%
No
6.1%
p-value
0.000
Yes
8.5%
No
3.9%
p-value
0.000
Ethiopia (2005)
Zimbabwe (2006)
3.2%
33.9%
1.6%
20.8%
0.004
0.000
1.4%
36.0%
0.9%
14.1%
0.247
0.000
Hospital Acquired Infections:

A nosocomial infection is one which is acquired during a patients 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 Ugandas 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-
15
extended shifts.(39) Intern doctors report making four times as many fatigue-related errors
leading to a patients 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 patients 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 patients 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
16
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)
17
Policy Options
National stakeholders in patient safety identified potential policy solutions to improve the
quality of Ugandas 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 Ugandas.
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
18
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.
19
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
Outcomes
Impact
With usual
nurse staffing
Length of stay
Readmission
Addition of
specialist
nursing post to
usual staffing
200 per 1000

(153 to 265)
Quality
of
of the
Participants
(studies)
evidence
Relative change
1.35 lower
(1.92 to 0.78
lower)
174 per 1000
Number
15% relative
increase
(GRADE)*
235
(2)
Moderate
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)
20
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 Organizations 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
Ugandas 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, handwashing 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)
21
Surveys by the Uganda National Health Consumers Organizations 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;
Participants 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.
22

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
patients 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.
23
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
Outcomes
Impact
With standard
care
Hospital
Emergency
Department
contacts
(all-cause)
1 year
Mortality (allcause)
1 year
Medication
review
Low Risk Population

100 per 1000
64 per 1000
(46 to 89)
Number
Quality
of
of the
Participants
(studies)
evidence
Relative change
36% relative
decrease
(GRADE)*
574
(3 studies)
Moderate
1002
(4)
Low
High Risk Population

300 per 1000
192 per 1000
36% relative
(138 to 267)
decrease
Low Risk Population
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
24
300 per 1000

Hospital
readmission
(all-cause)
1 year
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 reassessments 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
25
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)
26
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.
27
Table 9: Barriers to Improving Patient Safety and Proposed Strategies to overcome them:
Barrier
Recipients of Care
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
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)
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.
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)
Barrier
Providers of Care
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.
Evidence
Training of allied health professionals to perform
Educational meetings alone or combined with other

interventions, can improve professional practice and
healthcare outcomes for the patients.(80)
drug re-assessments. It is a professional prerequisite for

clinical officers to prescribe medications.
28
Barrier
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)
Evidence
Continuing professional education, outreach

visits, audit and feedback
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, 8285)
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.
Health Systems Constraints
Barrier
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)
Evidence
Financial and non-financial incentives
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)
Adequate remuneration, material and non-material

incentives are essential to motivate health workers.
29
Barrier
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)
Evidence
Health Insurance Schemes
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 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.
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 costrecovery. 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)
30
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 Patients Status
By
Machine/System/Environmental
Change/Alarm
By a Count/Audit/Review
Proactive Risk Assessment
31
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
32
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 Ugandas 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.
33
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
MOH
MDGs
HAI
ADE
DHS
United Nations
Ministry of Health
Millenium Development Goals
Hospital Acquired Infection
Adverse Drug Events
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.
34
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 patients 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)
35
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10 May 2014

An Evidence Brief for Policy

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Address for correspondence

SURE Supporting the Use of Research

The Regional East African Community

The Evidence-Informed Policy Network

GLOSSARY, ACRONYMS AND ABBREVIATIONS:

See Executive summary

Uncertainty does not imply indecisiveness or inaction

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

Patient Safety Action areas

Safe surgical care

MDG 4 Child mortality MDG 5

MDG 4 Child mortality MDG 5

Health worker protection

MDG 6 Communicable diseases

Surveillance and research for

All health related MDGs

Medical products, vaccines and

Health care waste management

MDG6 Communicable disease s

Funding for patient safety

All health related MDGs

Health systems services and

All health related MDGs

Develop and implement national

MDG 8 Partnership development

Knowledge and learning in patient

National Activities on Quality and Safety:

Size of the problem

All Routes totals

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

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

Women (15-49 years)

Men (15-49 years)

Knows to avoid HIV infection by avoiding:

Source: DHS/AIS 2003-2006

Women (15-49 years)

Men (15-49 years)

Source: DHS/AIS 2003-2006

Unsafe blood products and Blood transfusion:

Table 5: HIV Prevalence by Ever received a Blood Transfusion

Women (15-49 years)

Men (15-49 years)

Source: DHS/AIS 2003-2006

Hospital Acquired Infections:

Cause of the problem

Table 6: Adding dietary assistants to usual nurse staffing:

102 per 1000

146 per 1000

229 per 1000

131 per 1000

*GRADE Working Group grades of evidence

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

200 per 1000

*GRADE Working Group grades of evidence

Participants self-reported understanding of the trial described in the consent document

Relevance of the research findings to the Ugandan context:

Effectiveness of medication review in hospitalised patients

Table 8: Medication Review in Hospitalised Patients

Low Risk Population

High Risk Population