In Sub-Saharan Africa (SSA), there has been an increased number of hospital births following sustained efforts to promote births in hospitals (rather than the community), as part of a strategy to address high maternal and infant mortality. However, many patient safety researchers have indicated growing concern that a significant number of women are at risk of unintentional harm from the care they receive in hospitals. Improving the safety of birth care requires understanding the contributory factors to adverse events (AEs) within the hospital setting. Existing literature has described the contributory factors but often lacks sufficient detail on how and why these occur.
Methods
A systematic review of the literature to understand the type of AEs, their contributory factors and the extent to which identified AEs were considered preventable informed this study's focus and approach. This study, guided by a systems approach, proactively sought to understand latent conditions underpinning contributory factors to AEs within the O&G department of one Northern Nigerian Teaching Hospital and identify solutions that could be transferable to similar settings. A combination of qualitative methods was used to gain in-depth, rich data, including observations (126 hours) and in-depth interviews (32) with various staff members (doctors, midwives/nurses and senior hospital managerial staff) to reflect a wide range of perspectives and experiences. A thematic analysis of the data was undertaken.
Findings
The findings add to existing knowledge in two ways. Firstly, they affirm existing literature on the contributory factors to AEs in SSA hospitals. Insufficiencies in building structures, limited resources (material and human), and organisational culture challenges impede safe care for women and contribute to potential and actual AEs. The findings then provided an additional layer of understanding of what underpins these AEs contributory factors. The insufficient availability of resources was reinforced by an inefficient resource management system. The poor patient safety culture within the case study context was influenced by an inadequate standardisation in care processes and enforcement mechanisms, a lack of a performance management system, professional hierarchies and power conflicts, and poor women-centred communication. Secondly, the study provided an in-depth insight into AE reporting and management processes. There were three forms of staff responses to AEs and/or their contributory factors in the O&G department. Not all of them will proactively identify/address AEs and/or their contributory factors. These responses are influenced by many elements of organisational processes/systems and patient safety culture within the department and broader hospital.
Conclusions
Applying the system lens enhanced our understanding of the system weaknesses that underpin the contributory factors to AEs within a case study Nigerian hospital O&G department. While the findings highlight the need for increased provision and policies at the health system level, the study also proposes strategies that could address some of the issues currently compromising patient safety, which do not rely on additional funding. It is intended that the findings will support a proactive approach to managing risks in this setting, with much of the learning also potentially transferable to other hospitals and contexts.
