Common Medical Errors and Error Reporting Systems in Selected Hospitals of Central Uganda
[1]
Katongole Simon Peter, Faculty of Health Sciences, Uganda Martyrs University, Kampala, Uganda.
[2]
Robert Anguyo DDM Onzima, Department of International Public Health, Liverpool School of Tropical Medicine, Kampala, Uganda.
[3]
Miisa Nanyingi, Faculty of Health Sciences, Uganda Martyrs University, Kampala, Uganda.
[4]
Nakiwala Stella Regina, HealthPartners Uganda, Bushenyi, Uganda.
Medical errors are under studied in the developing world, therefore, this study set out to identify common errors committed during provision of health care and error management systems in the hospitals with reference to central Uganda. This was a descriptive cross sectional study carried out between January 16th and January 22nd 2012 in four hospitals in central Uganda (2 Public hospitals and 2 Catholic Private not for profit hospitals). A total of 160 health workers participated in the study. Respondents were interviewed the on errors they had committed or witnessed happening in their hospitals during the 3 months preceding this study. Patients’ records of the three months preceding the study were also reviewed to identify the common medical errors that had been committed. Of the six hundred and eighteen records that were reviewed’ medication (17.2%) and diagnostic (40.5%) were the commonest medical errors. Health workers too mentioned medication (58%) and diagnostic (53%) as the commonest errors they had witnessed or committed in the hospitals. No formal error reporting system existed in all the hospitals. Errors committed or witnessed were mainly disclosed to supervisors and/or colleagues during handover of duty and informal interactions. Lack of feedback, fear of punishment and litigation were the major impediments to disclosing errors. Error reporting importance was highly perceived by health workers. Instituting a mechanism of formal error reporting and management should be considered by the hospitals and the ministry of health so that errors can be used as a mechanism for ‘prevention by past experience’.
Medical Error, Error Reporting, Patient Safety, Quality of Healthcare
[1]
Linda TK, Corrigam JM, and Donalson MS. To err is human. Building a safer health system. Washington DC: Institute of Medicine, 1999.
[2]
Blendon R.J, Desroches CM, Brodie M, Benson JM, Rosen AB, Schneider E, Altman DE, Zapert K, Herrmann JM and Steffenson AE. Views of Practicing Physicians and The Public on Medical Errors. The New England Journal of Medicine, 2002; 347(24): 1933-40.
[3]
World Health Organization. World Alliance for Patient Safety: Towards a foward Programme. Geneva: World Health Organization Press, 2004 .
[4]
World Health Organization. World Alliance For Patient Safety: WHO draft guidelines for advance event reporting and learning systems. from information to action. Geneva: World Health Organization Press, 2005.
[5]
Edwards R. The WHO World Alliance for Patient Safety. A new challenge or an old one neglected. Drug Safety, 2005; 28(5): 379-86.
[6]
Waring JJ. Beyond blame: cultural barriers to medical incident reporting. Social Science and Medicine, 2005; 60(9): 1927-35.
[7]
Frankel A, Tejal KG and Bates DW. Improving patient safety across a large intergrated health care. International Journal of quality in Health Care delivery system, 2003; 15(1): 31-40.
[8]
World Health Organization,Regional Office for Africa. Make patient safety a priority for Africa, 2002. Available at: file://G:pt%safety.html (viewed on 29th November 2011).
[9]
Waring JJ. A qualitative study of the intra-hospital variations in incident reporting, Int J Qual Health Care, 2004; Vol.16, no 5:pp347-52.
[10]
Wezel TB. Patient safety: minimizing medical error. CME, 2012; 30(11): 406-09.
[11]
The Promota Magazine: Patient safety improvement in Africa (PASIMPIA). An interview with James Mwesigwa, nd. Available from: http://content.yudu.com/Library/A1ryxs/ThePromotaMagazineis/resources/28.htm. (Accessed on 3rd June 2015).
[12]
Sandars J. The theoery and evidence base for clinical risk management, in Keith H and Malcom T, ed. Clinical risk management in primary healthcare. Oxford: Radcliffe Publishing, 2005.
[13]
Kauffman M. ‘Medication Errors Harming Millions’. Washington post, July, 2006, A08.
[14]
Lawton R & Parker D. Barriers to incident reporting in a health care system. Quality and Safety in Health Care, 2002; 11: 15-18.
[15]
Terzibanjan AR., Raisa L, Weiss M, Airaksinen M and Wuliji T, 2007. Medication error reporting systems – lessons learnt.
[16]
Greens K., Blame free system increases medical error reporting (2011). [Internet]. Available from:www.reuters.com/.../us.blamefree.idUSTRE7A/NEWYORK, (Accessed 15th December 2011, 2:18).
