Background: Health care is one of the most
important services that every one desires to be of high quality and safety, but
in real practice, this is not always the case. In the event of seeking health
care, many patients are harmed and some get serious disabilities or even death.
System failures and blame for errors committed are the ones that mostly promote
occurrence of medical errors hence resulting into unsafe healthcare. Blame
prevents health care providers from reporting errors for future prevention of
safety, which is a component of quality healthcare, is defined as the absence
of avoidable harm to patients during the process of health care, (Carmen A. n.d.).
To achieve 100% absence of avoidable harm to patients is hard to realise as `to err is human`
but efforts to avoid harm are of great importance. In developed countries,
thousands of patients are reported to suffer serious harm and death in the
event of receiving health care services. In 1999,
Institute of Medicine in the USA estimated 44,000 to 98,000 preventable deaths
annually due to medical errors in USA hospitals, (IOM 1999).
In Uganda`s healthcare system, many patients are harmed and many even die
during the event of seeking for healthcare but due to poor reporting systems
there is limited information on the magnitude of preventable harmful medical
to determine patient safety culture of Iganga, Kakira and Kamuli Mission in
south eastern Uganda, had five objectives of; assessing the knowledge of health workers on patient safety, the role of
the hospital management in promotion of patient safety culture, determine
patient safety culture practices, point prevalence of common inpatient safety
incidents, and causal pathways.
The study was an observational,
descriptive and cross-sectional survey. A sample of 144 health workers were interviewed
using a questionnaire, three focus group discussions with hospital managers
were conducted, and 169 inpatient records were reviewed. Data was entered in
SPSS 16. 0 software then into Excel for further analysis and later presented in
The study revealed that the knowledge of health workers on patient safety in
the study hospitals was just above average at 55.8%. Under and over dosing of
patients, dispensing of wrong drugs and poor infection control being the most common medical errors known, where as Uganda clinical
guideline was found to be the most known guideline for patient safety. The study also showed that, the
majority of health workers would not report errors due to ignorance and fear of
blame. The study showed existence of team work and channels for communication
of patient safety issues between management and staff. However, management
role in promotion of patient safety is still demanding as there was limited
availability of policies and guidelines, lack of patient safety incident record
books and patient safety committees. There existed fairly good patient safety
practices as communication, hand washing, dispensing and team work were all
above average. However it was found out that poor reporting, fear of blame,
under staffing and inadequate waste disposal practices did exist. Incidents of
to monitor vital signs and delayed investigations were more prevalent in over
70% of all records studied. The majority of the
surgical operations were done without pre-operative investigations and had
inadequate post operative notes increasing the chances of harm to surgical
patients. Causal pathways for medical incidents were mainly
lack of guidelines and policies, poor monitoring of adherence to guidelines,
limited skills and training of staff, understaffing, heavy workloads, lack of
logistics and faultiness of equipments and lack of reporting procedures for
In conclusion, the level of knowledge on patient safety
culture is just average as
awareness is still limited. There is a
significant lack and limited availability of policies and guidelines,
incident record books and committees that promote patient safety. The bad
practices of fear to report incidents, under-staffing and fear of blame for
errors committed need improvement. Failure to monitor vital signs,
difficulty to access high skilled staff especially the medical officers and
inadequate post operative notes also need serious attention as they are part of
the causal pathways for patient safety incidents in the study hospitals. Provision
of policies and guidelines, training of health worker, management leadership
and effective communication and monitoring of patient safety in the study
hospitals are highly recommended.
 AHRQ (2007). Closing the
Quality Gap: A Critical Analysis of Quality Improvement Strategies. Volume 7, Number
9. www.ahrq.gov. Stanford University–UCSF
Evidence-based Practice Center, Stanford, CA.
 BATEGANYA MOSES, AMY HAGOPIAN, PAULA TAVROW,
SAMUEL LUBOGA AND SCOTT BARNHART 2009. Incentives and barriers to implementing national
hospital standards in Uganda. International Journal for Quality in Health Care 2009;
Volume 21, Number 6: pp. 421 –426 10.
 CARMEN AUDERA. n.d. WHO Patient Safety Programme-Meeting the challenges
Faced by Emerging Countries in the Provision of Quality Primary Health Care Cape
 CARMEN AUDERA-LOPEZ 2011. WHO patient safety programme 3rd annual conference
on safety, standards and customer services lagos 13th and 14th october 2011. WHO.
 DEPARTMENT OF HEALTH EXPERT GROUP 2000.
"An organisation with a memory". Department of Health, United Kingdom.
 DONABEDIAN A. 2005. Evaluating the Quality
of Medical Care. The Milbank Quarterly, Vol. 83, No. 4. Milbank Memorial Fund. Published
by Blackwell Publishing
 EU-PSWG 2007. Recommendations on patient safety by patient
safety working group. European commission
health and consumer protect general. Accessed on http://ec.europa.eu/health/archive/ph_systems/docs/ev_20080617_rd01_en.pdf
 IAPO (2008a), Uganda Health News: IAPO
Launches Patient Safety Toolkit. Kampala,
Uganda. Accessed from http://www.ugpulse.com/uganda-news/health/iapo-launches-patient-safety-toolkit/7054.aspx
 IAPO (2008b). Addressing global safety
issues. An advocacy toolkit for patients` organization
 INSTITUTE OF MEDICINE (IOM). 2000. "To
Err Is Human: Building a Safer Health System." In L.T. Kohn, J.M. Corrigan
and M.S. Donaldson, eds. Washington, DC: National Academy Press.
 LUWEDDE M 2011. Uganda Catholic Medical
Bureau Bulletin Jan - Dec 2011. Page 13-15
 MOH (2009), Uganda National Health Policy
 MOH (2011), Health Sector Quality Improvement Framework
and Strategic Plan 2010/11 – 2014/15.
 MOH (2005), Injection safety and appropriate
health care waste management. MMIS.
 ROSS BAKER, PETER G. NORTON, ET AL. (2004).
"The Canadian Adverse Events Study: the incidence of adverse events among hospital
patients in Canada". Canadian Medical Association Journal 170.
 WHO (2004), World Alliance for Patient Safety, Forward programme 2005. Accessed on
http://www.who.int/patientsafety/en/brochure_final.pdf on 8/3/2012.
 WHO (2008a), Better knowledge for safe
care, Global Priorities for Research in Patient Safety (first edition) The Research Priority Setting
 WHO (2008b), World Alliance for Patient
Safety WHO Guidelines for Safe Surgery.
 WHO (2009a pp106-147), Conceptual Framework
for the International Classification for Patient Safety Version 1.1 Final Technical
 WHO (2009c). Medicines use in primary
care in developing and transitional countries. Fact Book summarizing results from
studies reported between 1990 and 2006.
 WHO (2009d). African partnership for patient
safety: working for safer health care … together. World Health Organization, 20
Avenue Appia, 1211 Geneva 27, Switzerland
 WHO (n.d. b).