Research consultancy
CLINICAL ERRORS—THE UNCLASSIFIED DIAGNOSIS;
APPLICATION OF TeamSTEPPS TOOL TO EXAMINE THE IMPACT OF TEAMWORK ON CLINICAL ERRORS AT GULU HOSPITAL.
| ADR | Adverse Drugs Reactions |
| AEFI | Adverse Events Following Immunisation |
| AHRQ | Agency for Healthcare Research and Quality |
| ANOVA | Analysis of Variance |
| ARVs | Anti-Retroviral |
| CPOE | Computerized Prescription Order Entry |
| DHIS2 | District Health Information System |
| FACE-M | Functional Actions for Clinical Errors Management |
| FMEA | Failure Mode Effect Analysis |
| GRRH | Gulu Hospital |
| HEAPS | Human Error and Patient Safety |
| HEDIS | Healthcare Effectiveness Data and Information Set |
| HIV | Human Immune Virus |
| HMIS | Health Information Management System |
| ICD | International Classification of Diseases |
| IPD | In-Patient Department |
| MKP | Medical Knowledge Portal |
| MoH | Ministry of Health |
| NACOSTI | National Commission for Science, Technology, and Innovation |
| PPH | Post-Partum Haemorrhage |
| SEIPS | System Engineering Initiatives for Patient Safety |
| SDG | Sustainable Development Goals |
| SOPs | Standard Operating Procedures |
| SU-IREC | Strathmore University Institutional Research and Ethics Committee |
| TeamSTEPPS | Team Strategies and Tools to Enhance Performance and Patient Safety. |
| UHC | Universal Health Coverage |
| UHF | Uganda Healthcare Federation |
| WHO | World Health Organization |
Definition of Terms
| Terms | Definitions |
| Accident Causation Model | A model which proposed that clinical errors in the health system result from the interaction between latent pathology and human factors leading to active clinical errors |
| Adverse Events following Immunisation | an adverse or sentinel event that occurs following an immunization and can be linked to poor clinical practices |
| Clinical Errors | Mistakes of mishap due to human and system faults during patient care |
| Error of Commission | Overuse or using the wrong approach in patient care |
| Error of Omission | Underuse or lack of performing the required procedure in patient care |
| Heuristics | The grounded perception of experience that affects effective clinical decision process in the care of patients |
| Human Error Theory | The combination of factors that affects human interaction, engagement, and adaptation to their workplace |
| Human Factor Ergonomics | The system that is associated with the human interaction with their work environment and factors that affect their performance given data and information |
| Medical Knowledge Portal | A portal that enables the transfer of knowledge to enhance health workers’ skills and knowledge in promoting quality patient care |
| Ockham Procedures | The act of using fixed heuristics in the achievement of a desired outcome for patients |
| Oslerian Principles | The act of using standard principles set out in SOPs to achieve the desired results during patients care |
| Teamwork | The act of collaborating with each other to achieve a shared objectives and goals in patient care |
| The Swiss Error Theory | The error model and theory states clinical error occur as a result of latent and active faults in the health system |
| The System Engineering Initiatives for Patient Safety | Models and methods of work system design need to be developed and implemented to advance research in and design for patient safety |
| The System Error Theory | The theory proposes that clinical errors do occur in a patient as a result of latent or active system faults. |
CHAPTER ONE
INTRODUCTION
1.0 Overview
This chapter introduces the concept, background of the study, definition of team and teamwork, the terms and the typology of clinical errors, the context where the study was conducted.
1.1.Background of the Study
Every year, the United States (US) Health Statistics Department (HSD) compiles death certificates without including clinical errors as a cause of death, despite the fact that clinical error would be the third most common cause of death if it were a disease(Makary & Daniel, 2016). Clinical errors are any harmful or unfavourable events that occur to patients while they are receiving healthcare, both active and latent (Rodziewicz et al., 2024). Used interchangeably with medical errors, clinical errors can result from structural, processes, or outcome-based actions ranging from failure to complete an action for an intended goal to the application of incorrect policy, procedures, processes, and practices in healthcare to achieve a desired clinical outcome (Elden & Ismail, 2015).
Based on the 2004 report on inpatient deaths, the Agency for Healthcare Quality and Research for Patient Safety estimated that 575,000 deaths resulted from medical errors between 2000 and 2002, or about 195,000 deaths per year. This report refutes the 1999 Institute of Medicine (IOM) Report “To Err is Human”, which showed that only 140,400 deaths occur annually in the US due to medical errors. Further, the US Department for Human Health Services report that there is an error rate of 1.13% among Medicare beneficiaries. If this is used to calculate the rate of errors across all institutions registered in the US it translates to 800,000 deaths per year, a figure four times the IOM estimates(Makary & Daniel, 2016).
Preventable patient harm which includes clinical errors affect nearly 1/20 patients in healthcare setting (Panagioti et al., 2017). In essence, clinical error continues to highlight the shortcomings of the health system, particularly the ergonomics of the human system, due to five main causes, including: 1) observation error or projections of non-evidence; 2) attachment biases or avoidance of emotions; 3) the logic of presumption or extrapolation in the diagnosis process, including assumptions, experiences, and an excessive reliance on false beliefs; and 4) the action of omission and commission without adherence to due diligence (Kothari, 2012).
Recent a study in Kenya indicated that clinical error resulting from wrong or inappropriate choice of medications among cardiovascular patient was high, 74/97 patients with drug-drug interactions (95.2%) the leading error and wrong choice (45.0%) of drug errors (Mwavu, 2021). The study findings of the Kenyan study are similar to those of a study conducted in Uganda which showed that medication error stood at (53.2%) and were due to drug overdose (42.9%) and factors such as poor reporting, poor ethical leadership, and punitive measures to those who report or commit error were attributed (Mauti & Githae, 2019). However, from the positive development perspective on quality of care improvement, teamwork has been shown to enhance and reduce clinical error incidence and severity among patients in three hospitals in Kenya (Jepkosgei et al., 2022) though in another study teamwork was not significant in promoting team efficiency or reduction of clinical error incidence (Ntwiga et al., 2021). It must be noted that these studies were not a representation of the whole situation in the country but can inform us that there are clinical errors occurring in healthcare setting and requires further attention from policy makers.
These gaps in Total Quality Management especially in healthcare system has prompted the researcher to conduct further enquiries to understand the influence of teamwork on the outcome of clinical errors specifically in Gulu Hospital Uganda.
1.1.1 Teamwork in the healthcare setting.
Teamwork is the ability and capacity to collaborate effectively with other members to reach a shared objective or goal. Teams are groups of people, whether professional or non-professional, who work together to achieve a common goal (Merriam-Webster, 2012). In the healthcare setting, teamwork plays a critical role in ensuring better performance and reduced incidence and severity of clinical errors (Rosen et al., 2018). For example, teamwork among healthcare teams during patient care can improve patient monitoring, drug management, and surgical procedures, and reduce workload burden which can result in stress and errors (Mujumdar & Santos, 2014). A report in 2002 by the UK National Confidential Enquiry into deaths due to clinical errors indicates that over 70% of deaths in the emergency department were attributable to poor teamwork such as lack of effective communication, lack of shared responsibilities, consultations, and poor reviews of clinical care (Susan Mayor, 2002).
As diverse professionals work in different units and facilities yet handle the same patients within the healthcare setting, the concept of teamwork is less widely understood. For this it has been argued that teamwork needs to be understood from three angles; the temporal side of how teamwork emerges, should be sustained, and how does it affect clinical outcomes, secondly to understand how the context of operation of teams impacts on the overall shared goal, and lastly the understanding of the dynamic interaction among teams through communication, leadership, and mutual support in enhancing teamwork spirit (Anderson et al., 2021)
1.1.2 Clinical errors concept, causes, and categorization in healthcare setting.
Clinical errors are mistakes or careless acts, omissions and underuses, or commissions and overuses induced by deviations from ethical standards of practice (Oyebode, 2013a). The practitioner’s direct care responsibility must have been expected for a reasonable period of time. Medical errors are preventable unfavorable outcomes of medical care that occur before, during, or after an acceptable period of medical care. Both can harm the patient. Error in the medical field stems from the English law “tort” as outlined in the case of Donohogue vs Stevenson (1932) UKHL100, which established that one must have a legal duty to take reasonable care when relating to people likely to be affected by their actions; omission, breach, and neglect confer liability in the medical field (African Exponent, 2022).
Healthcare clinical errors can occur for a variety of reasons. The complexity of the system and its modern devices, the lack of a safety culture, the pressures of competing priorities like workload, staff inadequacy, and overambitious organizations, the inadequate application of evidence-based care, and the misalignment of goals, however, have been the most significant precipitating factors for error occurrence over the past 25 years. As an illustration, many firms continue to reward and offer performance based on output rather than outcome (Fain, 2019)
Two theories and models for clinical error occurrence in this study are; The Human Error theory which asserts that clinical error results from human cognitive or heuristic biases of availability, representativeness, anchoring, and adjustment (Zulekha Saleem, 2014). The System theory states that errors can occur due to active or latent conditions in the patient-provider environment (Reason, 2000b). However, the two theories do not take into account the impact and relationship of teamwork on clinical care outcomes. The System Engineering Initiatives for Patient Safety (SEIPS) developed on the Donabedian- Structure- Process- Outcome foundation posit that clinical error do occurs due to array of factors within and outside the health team(Kwan et al., 2021).
However, to bridge the gap in clinical errors and healthcare teamwork, the Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centred Medical Home care developed the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in 2008. The framework comprised of 5 domains Team structure, leadership and management, staff mutual support, situation monitoring, and communication do plays key role in improving providers practices especially within a team(King et al., 2008). Each of the five (05) domains are linked to different teamwork outcomes; that is appropriate team structures promotes responsible and accountable care by team members; ethical leadership and management enhances the use of standard operating procedures and promotes efficient operations; mutual support and situation monitoring reduces workload stress, conflicts during patient care, and promote feedback loop especially in vital signs monitoring of patients; and lastly effective communications during patients hands-off or inceptions are vital for reliable, adequate, and valid information sharing with teams all which are key to improving the healthcare team performance(Rosen et al., 2018). Since its development, the framework which uses a TeamSTEPPS Teamwork Perceptions analysis, has been a significant instrument in healthcare quality improvement and have offered vital evidence among teams in healthcare, notably in reducing clinical error incidences during the patient care continuum (Terregino et al., 2023).
Though clinical errors categorizations can take many forms, the commonly accepted nomenclature is presented in the table below.
| Category of errors | Examples in the clinical settings |
| Diagnostics | Error of delay in diagnosis
Failure to use indicated investigations Use of inappropriate investigations Failures to act on results of investigations |
| Treatment | Error in the performance of procedures
Error in administering medication Error in the dose of drugs Avoidable delay in treatment |
| Preventive | Failure to provide prophylactic treatment
Inadequate follow-up |
| Others | Failure of communications
Equipment failure System failures |
Advances in Psychiatric Treatment, (Oyebode, 2013a).
Table 1.1. Clinical error nomenclature in healthcare
1.1.3 Gulu Hospital.
Gulu Hospital is located in Gulu City one of the largest towns in the Acholi sub-region, located approximately 343 kilometres north of Kampala, Uganda’s capital city on the coordinate’s latitude: 20 46’28.45N; longitude: 320 17’ 56.36E. It was built in 1934 as a provincial hospital, and later became a district hospital until 1999 when it was made a Regional Referral Hospital according to the MoH gazettement.
The hospital serves as the referral facility for the eight districts in the Acholi sub-region, with a projected catchment area population of 1,751,000 (Strategic Plan, F/Y 2019/20). Through an Act of Parliament of Uganda, Gulu teaching hospital is destined to become a National Referral Hospital. It has all specialist departments with major specialists such as-Surgeons, Pharmacist, Orthopaedics, Psychiatrists, Physicians, Ophthalmologist, Pathologist, Oncologist, Paediatricians, Radiologists, MOs, Registered Nurses, Medical Clinical Officers, Allied Health Workers, and support staff.
Given that no such study of the impact of teamwork on the incidence and severity of clinical errors that has been done before in this hospital and this hospital being a teaching institution for both registered and non-registered medical and paramedical health workers, it would provide a good learning environment and opportunity for both policy makers, students, workers, and the Ministry of Health (MoH) in understanding the impact of teamwork in promoting quality of care and patient safety.
1.2 Problem Statement
World Health Organization (WHO’s) global report on patient safety showed clinical errors are becoming more prevalent. Yet 80% of clinical errors cause are preventable, every 4 out of 10 patients experience clinical errors and this accounts for four times hospital deaths (Nandasoma, 2019). Clinical error can significantly influence healthcare cost and a complicated consequence. For instance, clinical error can reduce a person’s life expectancy or hasten their demise.
Uganda has an 88.7% chance of clinical error in its healthcare setting (John, 2016). Some studies showed 58% and 53% are clinical errors due to diagnostics and medication errors (Anguyo et al., 2015). Lack of teamwork and effective communication, and poor reporting, among team contributes to this poor quality of care and patient safety (John, 2016). Yet good team composition of 4-5/1,000 patient reduces the incidence of clinical errors, insufficient team structure in Uganda 1-2/25,000 provider to patient, flawed system, processes, and events beyond healthcare provider’s control have led to clinical errors and death which could have been prevented (Jane N et al., 2022).
Studies conducted in Uganda documented links between clinical errors incidence and mechanism of reporting, detection, and management; however, few have shown the impact of teamwork among medical and paramedical staff on the incidence and severity of clinical error. For instance, Githae (2019), Anguyo (2015) both studied common mechanism of error reporting and prevention among nurses and physicians, Dorothy (2021) studied how policy and guidelines influence error occurrence, Balidawa (2016) showed that clinical error reporting and management were based on management rules. It is against this quality-of-care gap that the researcher is intending to determine the impact of teamwork on clinical error incidence and severity at Gulu Hospital, Uganda.
1.3 Research objectives
This section has outlined the general objective and specific objectives that guide the overall study
1.3.1 General Objective
The main objective of this study aimed to apply TeamSTEPPS tool to examine the impact of teamwork among medical and paramedical health workers on the incidence and severity of clinical error at Gulu Hospital in Uganda.
1.3.2 Specific Objectives
Specifically, the study aimed to:
- Determine the effects of team structures on the incidence and severity of clinical errors.
- To find out how team leadership affects clinical error incidence and severity.
- Examine how patient situation monitoring and mutual support affects the incidence and severity of clinical error.
- Determine the effects of team communication on the incidence and severity of clinical error.
1.4 Research questions
- Do team structures affect clinical errors incidence and severity in the hospital?
- What are the effects of team leadership on clinical error incidence and severity?
- How do monitoring of patient situation and mutual team support affect clinical error incidence and severity?
- How does effective team communication affect clinical error incidence and severity?
1.5 Scope of study
Gulu referral hospital was preferred as it’s the biggest referral hospital in Gulu City, serving 7 districts and it is supposed to become a teaching facility, whence it will be a great opportunity that change starts before its given the status of a teaching and referral hospital. A descriptive mixed cross-sectional approach was used to study the impact of team structures, leadership, situation monitoring, mutual support, and team communication on the incidence and severity of clinical errors. Both qualitative and quantitative data for the period between November 2022 and October 2023 were collected using structured and unstructured questionnaires specifically to enable triangulation of the findings from both primary and secondary data.
1.6 Significance of study
This study would benefit students, healthcare workers, and patients in the following ways. One, it will be useful for bridging the theoretical knowledge gap of healthcare practitioners thereby promoting teamwork as a tool for reducing clinical error incidence among patients. Secondly, it would provide feasible recommendation to improve policy on quality of care through implementation of routine clinical error detection, reporting, and management in the hospital. Lastly, the study would improve patient safety culture and environment for healthcare practice in the hospital, region, and nationally given that patient safety is a global health topic of concern in most modern healthcare systems.
1.7 Chapter Summary
Clinical errors are mistakes or negligent act that arises from human factor ergonomics largely influenced by external and internal environment and can take the form of omission or commission in patient care leading to poor outcome. Several factors convergence results into this safety concern, however, theories of human error and system error highlight that poor decision process and faulty systems or latent pathology in system configuration are responsible even if teamwork is being practiced. Appropriate teamwork which is grounded in the idea that team composition and structure, leadership, mutual support and patient’s situation monitoring, and effective communication should lead to better clinical care; hence it is vital for reducing clinical error incidence in the healthcare system.