Qualitative3-MedicalerrorsHealthcareprofessionals.pdf

RESEARCH ARTICLE

Medical errors: Healthcare professionals’

perspective at a tertiary hospital in Kuwait

Zamzam Ahmed
1
, Mohammad SaadaID

1
, Alan M. JonesID

2
, Abdullah M. Al-HamidID

1,2*

1 School of Pharmacy, University of Hertfordshire, Hatfield, United Kingdom, 2 School of Pharmacy,

University of Birmingham, Edgbaston, United Kingdom

* [email protected]

Abstract

Medical errors are of economic importance and can contribute to serious adverse events for

patients. Medical errors refer to preventable events resulting from healthcare interactions,

whether these events harm the patient or not. In Kuwait, there is a paucity literature detailing

the causes, forms, and risks of medical errors in their state-funded healthcare facilities. This

study aimed to explore medical errors, their causes and preventive strategies in a Kuwait

tertiary hospital based on the perceptions and experience of a cross-section of healthcare

professionals using a questionnaire with 27 open (n = 10) and closed (n = 17) questions.

The recruited healthcare professionals in this study included pharmacists, nurses, physi-

cians, dentists, radiographers, hospital administrators, surgeons, nutritionists, and physio-

therapists. The collected data were analysed quantitatively using descriptive statistics. A

total of 203 participants filled and completed the survey questionnaire. The frequency of

medical errors in Kuwait was found to be high at 60.3% ranging from incidences of pro-

longed hospital stays (32.9%), adverse events and life-threatening complications (32.3%),

and fatalities (20.9%). The common medical errors result from incomplete instructions,

incorrect dosage, and incorrect route of administration, diagnosis errors, and labelling

errors. The perceived causes of these medical errors include high workload, lack of support

systems, stress, medical negligence, inadequate training, miscommunication, poor collabo-

ration, and non-adherence to safety guidelines among the healthcare professionals.

Introduction

Medical errors (MEs) are one of the common causes of iatrogenic adverse outcomes in the

healthcare industry. A ME is defined as a failure to achieve planned actions (errors of execu-

tion) or using wrong plans to attain an objective (errors that result due to planning) [1]. An

unintentional act (either of commission or omission) or an act that fails to achieve its planned

outcome is another definition for MEs [2]. It is argued that often, there are circumstances

beyond the control of the healthcare provider that influence patient outcomes [3]. For

instance, a patient may present with an unknown allergic reaction after receiving a new medi-

cation. In this case, the allergic reaction is the unexpected or unplanned outcome, yet it cannot

be holistically argued that the outcome is attributable to ME.

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OPEN ACCESS

Citation: Ahmed Z, Saada M, Jones AM, Al-Hamid

AM (2019) Medical errors: Healthcare

professionals’ perspective at a tertiary hospital in

Kuwait. PLoS ONE 14(5): e0217023. https://doi.

org/10.1371/journal.pone.0217023

Editor: Mojtaba Vaismoradi, Nord University,

NORWAY

Received: January 12, 2019

Accepted: May 2, 2019

Published: May 22, 2019

Copyright: © 2019 Ahmed et al. This is an open
access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript and its Supporting

Information files.

Funding: The author(s) received no specific

funding for this work.

Competing interests: The authors have declared

that no competing interests exist.

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Patient safety is a basic patient right and should be ensured during hospital visits or admis-

sion [4]. Furthermore, it is the duty of healthcare professionals (HCPs) and institutions to

ensure patient safety, improve treatment outcomes and reduce adverse events (AEs) [4]. A fail-

ure to provide safety may result in death, disabilities, poor health outcomes, increased costs

and legal issues [4]. It is noted that MEs and AEs are inevitable in almost all healthcare settings

[5]. A recent report on healthcare quality advocated the need for a thorough approach to MEs

in the Middle East [6]. In addition, the authors emphasised the need for learning and identify-

ing MEs through voluntary and mandatory reporting systems [6]. Undertaking such an

approach would be essential in addressing significant AEs that occur in day to day activities in

the healthcare sector.

In the light of the above study characteristics and demographic trends in the Middle East

regarding MEs, it is important to explore the potential causes and preventive measures of MEs.

Exploring MEs from the perspective of the HCPs is crucial in early mitigation of potential

errors. Preventing MEs will be of economic importance to the healthcare industry in terms of

reducing unnecessary rehospitalisations, and diagnosis [7]. Moreover, MEs prevention is

important in promoting patient safety culture (PSC) and eliminating financial burdens on

healthcare institutions, and families of the affected patients [4, 8]. In addition, prevention of

MEs can help mitigate other adverse outcomes such as permanent disability, complications,

and death [9, 10].

There is a paucity of data available on MEs in Kuwait’s healthcare industry. There have

been very few academic studies in this field in Kuwait [10, 11]. A study conducted in 2014 eval-

uated PSC in Kuwait and reported that participants (nurses, physicians and administrative

staff) rated patient safety at their workplaces highly, with 74.1% reporting no events that com-

promised patient safety in the last one year [10]. Only 13.0% reported one or two AEs within

the same time period.

Ali and colleagues found that when assessing PSC in Kuwait, the hospital management

lacked critical unit-level systems such as non-punitive responses, open communication chan-

nels, and staffing important to improving patient safety [11]. Similarly, the study conducted by

Ghobashi and colleagues revealed in their research that respondents identified non-punitive

response to errors, communication openness and adequate staffing was essential in ensuring

patient safety [10]. However, the respondents indicated that they did not compromise patient

safety to get more work done implying that the perception of patient safety among medical

workers was high. While another study explored PSC in Kuwait among hospital staff [11],

Ghobashi and colleagues only investigated awareness among primary healthcare providers

about PSC [10].

The present study aims to ascertain the perceptions of HCPs about the causes and preventa-

tive measures of MEs in a Kuwait tertiary hospital.

Materials and methods

Research strategies and design

In this cross-sectional study, a quantitative research approach was used including open-ended

(n = 10) and closed (n = 17) survey questions. The use of quantitative surveys was preferred

for this study because it was a versatile design, allowing for a variety of methods to recruit par-

ticipants and collect data using various tools and instruments.

Research setting and participant sampling technique

The research setting was limited to a Kuwaiti tertiary hospital where the research participants

included HCPs from all the departments. A random sampling technique was employed to

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recruit participants from each department for inclusion in the study. Random sampling

ensured that everyone in the target population had an equal opportunity of being drawn into

the research. By using random sampling the likelihood of bias during the selection of partici-

pants was minimised and sampling errors were reduced [12]. A sample of 203 participants

(due to resources, time, and study objectives) comprising of HCPs from various departments

such as pharmacy, nursing, physicians, and administrators were recruited for the study

through random sampling.

Data collection tool

The tool for data collection was a self-administered open and closed-ended questionnaire (S1

Appendix). The questions were written by MS, reviewed by the research team then translated

into Arabic and further refined in the pilot stage described below. The questions were grouped

under three sections, each exploring a specific theme.

Section one of the questionnaire sought to collect demographic profile of the respondents,

including the participants’ age, gender, nationality, qualifications, position, the department

they practised in and years of experience.

The second section of the questionnaire assessed the knowledge of the participants regard-

ing MEs and inquired whether they had witnessed or had been part of a ME and the conse-

quences. Finally, the last section of the questionnaire explored the attitudes and opinions of

participants about initiatives to minimise or prevent MEs. The different parts of the question-

naire are summarised in the supplementary material.

Data collection procedure

The questionnaire was self-administered, and participants were required to take the survey

either online (using SurveyMonkey) or on paper format. The distribution of questionnaires

was done online and in such a way that the researcher was not in a position to tell who com-

pleted the survey questionnaire. The link to the survey was emailed to participants. No identifi-

able personal data was collected during the surveying process. The questionnaire was also

printed and made available at reception desks from where respondents could collect them and

also return after completion.

Data analysis

Descriptive statistics were used to summarise aspects of the data to provide information about

the sample as well as the population from which it was drawn [12]. Frequencies and percent-

ages were used to summarise the data. Frequencies are commonly used with discrete variables.

Relative frequencies were used to show the proportions of the sample and consequently, the

population, in terms of age, gender, length of work, and area of specialisation. Moreover, fre-

quencies and percentages were also used to analyse the data from the scale-based questions

where respondents selected one answer from given options. The number of respondents who

gave a certain response out of the total number of respondents were provided to show the per-

spectives of the healthcare professionals towards a certain metric. The summaries derived

from the descriptive analysis were presented in charts and tables.

Questionnaire pilot study

A pilot study was conducted with ten respondents due to the study resources. The pilot study

aimed to test the face and content validity of the questionnaire. The pilot study also assessed

the research protocols and recruitment strategies [13]. The pilot survey also enabled the

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researcher to make any modification needed and clarify vague questions. A total of five ques-

tions were modified as a result of the pilot study.

Potential research risks

The most significant risks associated with this research are linked to the aspects of confidenti-

ality. Past literature studies have shown that there are feelings of shame, guilt and panic after

the occurrence of MEs among HCPs [14]. HCPs may be afraid for their reputation, career,

future, and even their medical licenses if they admit to committing MEs [15]. Therefore, there

might be a risk of respondents refusing to participate due to guilt and fear as well as uncer-

tainty about confidentiality. The researcher informed the participants that their confidentiality

would be guaranteed, data obtained anonymously.

Potential ethical concerns

Ethics Committee approval was obtained from the Kuwait Ministry of Health and the Univer-

sity of Hertfordshire, UK prior to commencement of the study. Participants were informed

that taking part in the study was voluntary and that they were free to withdraw from the study

at any time. No identifiable or personal data was collected, and confidentiality was guaranteed

as discussed above. The participants were assured that the data was collected for academic

research only and that the collected information would be securely stored in a password

encrypted computer to prevent unauthorised access in efforts of ensuring information

confidentiality.

Results

Demographic characteristics

A total of 203 out of the 206 participants approached responded representing a response rate

of 98.5%. Out of the 203 respondents, there were a total of 84 (41.4%) male participants and

119 (58.6%) female participants (Table 1).

As further shown from Table 1, the majority of the participants (41.4%, n = 84) were aged

between 30 and 39 years followed by those that fell in the age bracket of 25–29 years, 40–49

years, under 25 years, 50–59 years, and above 59 years respectively. In terms of career occupa-

tion, most participants that took part in the survey were pharmacists (51.7%, n = 102), fol-

lowed by nutritionists (8.3%, n = 17), physicians (7.8%, n = 16), radiographers (5.4%, n = 11),

administrators (3.9%, n = 8), and dentists (3.9%, n = 8). Participants were also asked to share

their opinion in terms of job satisfaction at their present workplace. The feedback revealed

that 64% (n = 130) of the participants were satisfied, whilst 36% (n = 73) were not satisfied

with their work, respectively.

Common medical errors in Kuwait’s tertiary hospital

A total of 44.6% of respondents confirmed that they had encountered potential MEs while

55.4% had not experienced any MEs in their practice. Table 2 shows the potential MEs that are

commonly encountered in Kuwait healthcare facilities according to the participants. As shown

in Table 2, the main common types of MEs include making wrong dispensations, prescrip-

tions, dosage, explanation/descriptions, diagnosis, and drug formulation. According to the

participants, other MEs such as dispensing wrong medical results from lack of enough time to

review orders for appropriateness which results in increased likelihood among care providers

to make mistakes. Also, lack of tools to help clinicians to check drug-drug interactions espe-

cially in polypharmacy prescriptions resulted in high MEs.

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Table 2. Main medical error themes identified by healthcare professionals (HCPs).

Medical errors (MEs) Response (n, %)

Dispensed medication with incomplete instructions 19 (33.5)

Prescribed drugs to the incorrect patient / no check for patient drug allergies 19 (33.5)

Incorrect dose or overdose for adults and paediatric patients 18 (31.8)

Wrong administration of medicines to patients 16 (30.0)

Wrong explanation of medication usage 15 (29.5)

Wrong diagnosis when first admitting the patient 15 (29.5)

Similar medication brands–difficult to distinguish 14 (27.1)

Drug formulation unsuitable for patient condition 11 (24.4)

Dispensing antibiotics very often without appropriate tests conducted 9 (21.7)

Potential errors when entering patient data 8 (20.6)

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Table 1. Demographics and characteristics of the healthcare professionals (HPCs) included in the study

(n = 203).

Characteristic Variables n (%)

Gender Male 84 (41.4)

Female 119 (58.6)

Age (years) <25 13 (6.4) 25–29 65 (32) 30–39 84 (41.4) 40–49 30 (14.8) 50–59 7 (3.4) >59

NR

4 (2)

124 (61.1)

Educational level Doctorate 15 (7.4)

Masters 36 (17.7)

Bachelors 115 (56.7)

Diploma 37 (18.2)

Certificate 0 (0)

Specialism� Radiographer 11 (5.4)

Administrator 8 (3.9)

Dentist 8 (3.9)

Pharmacist 102 (51.7)

Surgeon 2 (1.0)

Nutritionist 17 (8.3)

Physiotherapist 4 (2.0)

Nurse 4 (2.0)

physician 16 (7.8)

Others e.g. laboratory technicians, oncologists

NR

28 (13.7)

5 (2.5)

Experience (years) <1 yr 41 (20.2) 1–3 yrs 15 (7.4) 3–5 yrs 50 (24.6) 5–10 yrs 40 (18.2) >10 yrs 57 (28.1)

NR: not reported,

�: Specialism: area of participant’s expertise

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The participants were asked about relationship between colleagues as they may have a bear-

ing in mitigating potential MEs. The workplace relations among the participants ranged from

perfect (26.6%), satisfactory (41.8%), compromised (29.8%), to bad (1.3%). It was evident from

61.4% of the participants that the state of the relationship with other colleagues largely affects

the credibility of the service that individuals provide, and thus the potential for MEs. However,

38.6% of the participants expressed that the state of workplace relationships does not affect or

compromise service delivery.

Where medical errors occur

The questionnaire aimed to identify areas where MEs commonly occurred in the medical facil-

ity in Kuwait. As indicated in Table 3, the participants reported that the common areas where

MEs occurred include the emergency room (57.0%, n = 112), medical wards (43.3%, n = 86),

operation rooms (33.1%, n = 66), Intensive Care Units (ICUs) (17.8%, n = 35), and while other

locations (17.8%, n = 35) account for the remaining MEs. In addition, Table 3 also shows the

additional areas where the MEs were likely to be reported including the out-patient depart-

ment, clinics, during hospitalisation, dietary department, negligence by nurses who do not

take care of the patient, pharmacy, and during diagnosis.

Participants were asked to share their views on who holds the largest responsibility for the

regular MEs encountered in the hospital environments. The respondents noted that fellow col-

leagues (49.7%) were to be held accountable for MEs, followed by the system used to run the

hospital facility (40.3%), and the hospital administration (27.0%). In addition, other partici-

pants (20.8%) also expressed that patients were to blame for MEs, while other respondents

indicated that various departments were responsible for MEs (7.6%).

Causes of medical errors

The survey sought to identify the most common causes of MEs. Table 4 shows the main

responses on the causes of MEs in Kuwait based on participant insights.

Potential impacts of medical errors

We aimed to identify the participants’ views about the potential negative impact that they had

encountered in the healthcare centre as a result of MEs. Table 5 summarises the potential

impacts of MEs from the participants’ perspectives.

Table 3. The main areas where medical errors are commonly encountered.

Hospital Department n (%) �Others (in detail) n (%)

Operating room 66 (33.1) OPD (out-patient department) 8 (4.0)

Emergency room 112 (57.0) Clinics 7 (3.5)

Wards 86(43.3) During hospitalisation 6 (3.0)

ICU 35 (17.8) Dietary department 4 (2.0)

Others 35 (17.8) Infection control is not sufficiently effective 4 (2.0)

Nurses do not take care of patient 4 (2.0)

Pharmacy 4 (2.0)

diagnosis 3 (1.5)

Anywhere in the clinic 3 (1.5)

� Open ended responses

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Participants were asked to estimate the frequency of the MEs they have encountered and

the nature of their occurrence at their workplaces. The majority of participants (60.5%) indi-

cated that they had encountered MEs on rare occasions compared to 15.3% of the participants

that had experienced MEs often, 11.5% who had not encounter errors, and 12.7% of the partic-

ipants that had never encountered MEs.

Potential solutions to medical errors

We asked participants to identify possible mitigation strategies that could be used to address

the potential MEs identified. A range of different suggestions were provided including report-

ing through incident reports (68.7%), taking advice from colleagues that were more experi-

enced (27.3%), and ignoring the incident (2.7%). Other strategies (1.3%) such as reaching out

to the patient before taking the medication and engaging with colleagues to improve service

delivery were used to reduce potential MEs.

When participants asked if they were personally involved in MEs, only 5.3% of participants

reported that they had committed a mistake that led to disability or death of a patient while the

majority of participants (94.7%) had not. Participants were asked about their views on the

potential role that health institutions have in the reduction of MEs. The participant responses

are summarised below:

1. Participants noted that health institutions could facilitate the creation of awareness (57.3%),

through seminars and workshops for healthcare providers.

2. In addition, 50.7% of the participants noted that encouraging workers and auditors to

report MEs was also an important avenue that healthcare institutions can use to reduce

MEs.

Table 4. The common causes of medical errors in Kuwait.

Main Cause of MEs n (%) �Other causes of MEs n (%)

Miscommunication between patients & HCPs 124 (62.7) High workload 23 (11.6)

Miscommunication between HCPs 70 (35.4) Stress & long duty hours 19 (9.5)

Lack of rest breaks for HCPs 59 (30.0) Lack of electronic systems 19 (9.5)

Others 30 (15.3) Diagnosis / efficiency of doctors 17 (8.5)

Lack of attention / carelessness 17 (8.5)

Untrained personnel 16 (8.0)

Ignoring / Negligence 16 (8.0)

Lack of national prescribing guidelines 8 (4.0)

Lack of experienced administrative workers 7 (3.5)

� Open ended responses

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Table 5. The potential impact of medical errors.

ME impact n (%)

Death of patient 41 (20.8)

Side effect to the patient 64 (32.1)

Hospital (re)-admission treatment 66 (33.3)

No negative effects 70 (35.2)

Other 5 (2.5)

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3. A total of 64.7% of the participants felt that health institutions should be more proactive in

terms of performing regular analysis and evaluations. Such an approach would help deal

with MEs through the analysis to find out the cause of the problem and establish a system

for not repeating this error.

4. A total of 44.7% of the participants express that the problem of MEs can be mitigated if

health institutions created a better working environment for workers to reduce working

hours and reconsider the system of shifts and considering to reduce the number of patients

who admitted to the hospital.

5. Other potential approaches (as expressed by 5.3% of the participants) that can be used by

health institutions to mitigate against MEs include (i) encouraging communication

between departments as well as and making people accept the fact that discussing errors to

correct them will benefit the overall outcome for patients. (ii) All workers in the health field

must be held accountable and submitted for investigation and legal accountability without

exception. (iii) encourage reporting by the workers and other stakeholders, and (iv) reduc-

ing workload or increasing the number of HCPs to reduce workload and give employee

flexible work schedules that help them achieve work-life balance.

Potential initiatives by health institutions that may aid a reduction in ME incidents

included the following as noted by the participants; raising awareness about medical responsi-

bility; encouraging employees and auditors to report; perform regular analysis and evaluation;

creation of a conducive working environment. The following initiatives were also noted by

fewer participants; encourage communication between all departments, emphasising that

every healthcare worker should be responsible, encourage reporting and discussing possible

errors, creation of further hospitals to reduce patient populations per hospital.

Participants were asked if experience and training through workshops and other learning

models can help the care providers improve their accuracy when serving the patients. Majority

of the participants (94.6%) noted that training and experience were important compared to

5.4% who felt that training did not influence the HCPs’ service delivery to the patients.

Barriers to reporting

Nearly half of the survey participants (45.3%) indicated that they report errors if and when

they occur, while the remaining 54.7% of the participants noted that they do not report errors.

The findings of the survey showed that reporting of MEs may be hindered by various factors.

The participants reported some of the hurdles they encounter when reporting MEs can be

attributed to organisational culture (56.5%), lack of knowledge (47.6%), and complex inci-

dence reporting forms (38.1%).

Moreover, the additional hurdles that participants identified as alternative hindrances to

reporting of MEs include: The fear ME reports will be used to blame other departments, Lack

of knowledge about the need and importance to write incident reports, People feel discouraged

when they report an error, and they do not see an end result. Fear of legal liability and prosecu-

tions, staff are afraid of legal action, Fear of the consequence that may result from ME, Lack of

seriousness in dealing with medical accidents, Some of the staff ignored MEs and indifference,

Lack of feedback and fear of consequences.

Participants were asked to suggest strategies that can be embraced to reduce the effect of

the MEs on the patients’ health. Some of the recommendations included:

1. The need to disclose the information about the error to the patients as suggested by 72.3%

of the participants.

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2. According to 50.7% of the participants, the management should give the patient’s means of

assessing the effectiveness of assistance following MEs.

3. The other 4.7% of the participants advocated that the reduction of MEs can be achieved

through:

i. Double checking records before making final decisions.

ii. Having an end result to the reporting and have a response from the administration and

the directors which may show that they care to change things into a better environment.

iii. Promoting a culture of transparency, dialogue, and openness.

iv. Rejecting temptations of covering up or favouring colleagues that have made mistakes,

reducing workload in the hospital.

v. Hiring HCPs with sufficient knowledge and experience in their fields.

Discussion

MEs play a significant role in influencing the safety of patients in Kuwait. The research focus

was to investigate the triggers of MEs and strategies that can be adopted and implemented to

reduce future occurrences of MEs.

In line with research Objective 1, the data drawn from the present research revealed that

the frequency of MEs in Kuwait is high. 60.5% of the survey participants indicated that they

have encountered MEs on frequent occasions and an additional 15.5% of the participants that

experience MEs often. In total, 76.0% of the participants have experienced MEs on a regular

basis. …