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Abstract
Preventing and reducing risks and harm to patients is of critical importance as unsafe care is a leading cause of death and disability globally. However, the lack of consolidated information on patient safety policies and initiatives at regional levels represents an evidence gap with implications for policy and planning. The aim of the study was to answer the question of what patient safety policies and initiatives are currently in place in the Middle East and Asian regions and what were the main strengths, weaknesses, opportunities and threats in developing these. A qualitative approach using online focus groups was adopted. Participants attended focus groups beginning in August 2022. A topic guide was developed using a strengths, weaknesses, opportunities and threats framework analysis approach. The Consolidated Criteria for Reporting Qualitative Research checklist was used to ensure the recommended standards of qualitative data reporting were met. 21 participants from 11 countries participated in the study. Current patient safety policies identified were categorised across 5 thematic areas and initiatives were categorised across a further 10 thematic areas. Strengths of patient safety initiatives included enabling healthcare worker training, leadership commitment in hospitals, and stakeholder engagement and collaboration. Weaknesses included a disconnect between health delivery and education, implementation gaps, low clinical awareness and buy-in at the facility level, and lack of leadership engagement. Just culture, safety by design and education were considered opportunities, alongside data collection and reporting for research and shared learning. Future threats were low leadership commitment, changing leadership, poor integration across the system, a public–private quality gap and political instability in some contexts. Undertaking further research regionally will enable shared learning and the development of best practice examples. Future research should explore the development of policies and initiatives for patient safety at the provider, local and national levels that can inform action across the system.
- Patient safety
- Quality improvement
- Health services research
- Global Health
- Qualitative research
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Patient safety policies and initiatives have been shown to be successful in reducing harm when implemented in national or subnational contexts internationally, with varied success rates, as well as opportunities and challenges.
WHAT THIS STUDY ADDS
This qualitative analysis of strengths, weaknesses, opportunities and threats provides greater insights on the range of opportunities and challenges which impact patient safety policy and initiative success in the Middle East and Asian regions.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Given the importance of patient safety in reducing deaths and disabilities globally, it is important to develop regional learning on developing policies and initiatives that can inform best practice and improvement.
Introduction
Unsafe care is 1 of the 10 leading causes of death and disability globally. Improving the safety and quality of care is essential to achieving universal health coverage and better health outcomes in the Middle East and Asia where adverse events and patient and healthcare worker (HCWs) awareness are still an important challenge to be addressed across health systems.1–3 Over the last 20 years, improvements have been made in reducing preventable harm, in part through global initiatives, including the WHO ‘My Five Moments for Hand Hygiene’ campaign and other guidelines to prevent healthcare-associated infections.4 5 In 2021, the WHO published the ‘Global Patient Safety Action Plan’ providing a framework to meet seven objectives (policies, reliable system, safety of clinical process, patient and family engagement, education, information and partnership) by 2030.6
With its basis in recognising and reducing adverse events,7 patient safety is a broad ranging concept with implications across disciplines, conditions, treatments and facilities. As such, prioritisation is a challenge for health leaders, providers and HCWs across and within health systems. In 2010, the WHO commissioned a study to establish priorities for global patient safety, set direction to improve research methods and tools, and encourage further research in low-income and middle-income countries.8
Given the distinctions between priorities at the global and subglobal levels, regionally focused research has enabled a nuanced understanding of patient safety successes, challenges and priorities. In the Middle East, for example, a study of patient safety policies and practice described regional and national-level activities but did not evaluate the facilitators and barriers to improving patient safety.9 A systematic review status of patient safety culture in Arab countries based on the findings of the Hospital Survey on Patient Safety Culture (HSPSC) similarly identified a pervasive culture of blame across the region, but the researchers focused on safety culture as only one element related to patient safety.2 Similarly, Kang et al undertook comparative research on patient safety culture in Southeast Asian countries, which identified 13 studies using the HSPSC survey.10 Analysis showed safety culture varied from low to moderate between countries, and that systematic and human factors influenced patient safety culture at the regional level, but again the research covered one area related to patient safety. Beyond academic research, a variety of regionally specific policies and initiatives have been established and reported on, but are hosted across different databases and stakeholder websites making it challenging to capture the breadth of activity regionally.
The lack of joined-up information on patient safety policies and initiatives at regional levels represents an evidence gap. It is important to gain expert insight and perspectives in the field of patient safety to track and facilitate progress. Currently, there is a sparsity of information on priority areas, as well as opportunities and challenges to drive new, or realise existing, patient safety policies and initiatives to improve patient safety. Quantitative research is not sufficient to collect detailed and nuanced information required to close this knowledge gap, instead qualitative focus groups enable researchers to elicit in-depth information from participants who can express themselves and clarify responses during the session, and can respond to and build on each other’s responses. This qualitative study provides a snapshot of policies and initiatives by exploring regional perspectives the main strengths, weaknesses, opportunities and threats (SWOTs) to developing patient safety policies and initiatives from a group of experts working in the Middle East and Asian regions.
Methods
Overview of the methods used
A qualitative approach using online focus groups was adopted to meet the study objectives. Focus groups are a method designed to enable the exploration of individual perspectives, facilitate discussion and ideas based on group dynamics and engagement.11 Online focus groups were selected to enable maximum participation across the sample and bring individuals from different health systems together to discuss regional policies and priorities, which would not have been logistically possible without the digital conferencing technology used (Microsoft Teams). A recognised methodology for conducting focus groups through videoconferencing software developed by Abrams and Gaiser is widely used in academic research.12 Researchers at The Riphah Institute of Healthcare Improvement & Safety (RIHIS) and Institute of Global Health Innovation (IGHI) with previous qualitative research experience performed the study. The process (both the design of the research and procedure followed) was underpinned by the recommended standards of qualitative data reporting outlined in the Consolidated Criteria for Reporting Qualitative Research and relevant information from the checklist is reported in the manuscript (eg, sampling, method of approach, sample size).13
Recruitment
Participants were recruited through RIHIS as individuals working in roles with a focus on patient safety and attended focus group meetings beginning in August 2022. The IGHI research team agreed on a participant list with RIHIS and sent invitations via email. Convenience sampling was used. The inclusion criteria were experts working with a focus on patient safety, or who are patient safety leaders in the Middle East and Asian regions. The predefined exclusion criteria excluded those who did not have any involvement in patient safety activities at a national or regional level.
Data collection
Eight focus groups were conducted between August and December 2022. The focus groups were facilitated using Microsoft Teams teleconferencing software. Each was recorded, and transcripts, hosted on secure servers, were compiled verbatim. To minimise bias, all focus groups were conducted in English and had minimal knowledge of the research team.
The topic guide (Multimedia online supplemental appendix 1), including open-ended questions, was used to cover relevant topics related to patient safety priorities during the focus groups, using a SWOT analysis approach. An SWOT analysis is a technique used to help organisations to identify these key topics in a structured way to enable strategic planning and improvement by identifying internal and external factors, both favourable and unfavourable, that impact the adoption of a project, a solution, an action or a set of actions (eg, patient safety policies and initiatives).14 The approach has further been used in health research to support healthcare organisations and public health, including focusing on patient safety initiatives.15 An example of this approach includes the use of SWOT to integrate the WHO patient safety curriculum into undergraduate medical education in Pakistan.16 To best answer the research question on patient safety priorities regionally, we adapted the SWOT analysis to consider strengths and weaknesses as current factors (rather than internal) and opportunities and threats as future factors (rather than external), enabling an assessment of implications on future policy and practice. The topic guide was designed with specific questions to integrate the SWOT analysis into focus group discussion, although this was checked and agreed by the research team during postdata collection analysis of focus group data.
Supplemental material
Data analysis
The focus group transcripts were systematically reviewed by two independent researchers (MS and NO’B), using deductive thematic analysis. The framework analysis method was used to determine the process and actions of the analysis: familiarisation, identifying themes, indexing, charting and summarising, and mapping and interpretation.17 The term policy was defined as ‘a plan, course of action or set of regulations adopted by government, businesses or other institutions designed to influence and determine decisions or procedures’ to ground subsequent analysis of the transcripts to generate codes and themes. The framework analysis approach was selected as offers used within multidisciplinary teams whose members have varying levels of experience with qualitative research.18 At every stage of the data analysis, the coding process was both deductive, based on the topic guide and researcher experience with the topic, and inductive to enable the development of emergent codes and themes, which were supported by relevant participant quotations. Following the initial analysis, themes were presented to a third reviewer (AS) using the Mural visual collaboration platform and discussed among the three researchers (MS, NO’B and AS) to identify any discrepancies, amend final wording and agreed. The researchers also discussed data saturation which was believed to be met based on no new themes emerging following the analysis of the final two focus group transcripts.
Results
Participant characteristics
A total of 21 participants were included in the study. They represented 11 countries across the Middle East and Asian regions, with the majority of participants coming from Pakistan (table 1).
Description of focus group participants by country
Categorisation of themes
Responses to the questions ‘What patient safety policies have been released in your region recently?’ were categorised across five themes and ‘What are good examples of patient safety initiatives taking place at the present time?’ were categorised across 10 themes (table 2). As noted, the term policy was defined as ‘a plan, course of action or set of regulations adopted by government, businesses, or other institutions designed to influence and determine decisions or procedures’, which is distinct from initiatives which encompass a broader range of patient safety activities that fall outside of policy actions.
Reported patient safety priorities and initiatives in the region
In response the question ‘What facilitated the release of patient safety policies’? responses were categorised into four themes: accountability, advancements in health policy, leadership and national-level regulations. Accountability subthemes were awareness of the need for healthcare improvement and awareness of patient safety through serious incidents. Specific advancements in health policy included COVID-19 and pandemic management.
COVID-19 was a blessing in disguise, an eye opener for all of us that we need to do more in healthcare. […] we developed and launched national guidelines for infection prevention and control Participant 21
Themes emerging through analysis of responses to the question ‘What impedes the development of patient safety policies at the present time in your region?’ included: community acceptance, lack of research, leadership, legal and regulatory, patient and public involvement engagement, policy, political instability and resources, including the health sector not prioritised and a lack of human resources/expertise.
I think the one of the most important reasons for the delay in implementation of patient safety policies is that the healthcare sector is not in the top priority areas of the government. Participant 8
We have yet to develop a dedicated team at a ministry level or in the hospital levels, which would just concentrate on policies, their implementation, and their upgrading Participant 14
The full list of themes and subthemes are presented in online supplemental appendix 2.
Supplemental material
SWOT analysis of patient safety initiatives
The framework analysis of the SWOTs related to patient safety initiatives identified overarching themes (table 3).
SWOT analysis
Discussion
Key findings
Current regional patient safety policies described by research participants include laws/regulations (eg, AMR regulations such as the Pakistan Anti-Microbial Resistance National Action Plan), policies (eg, National Blood Transfusion Policy in Pakistan, communicable disease policies and workforce policies in countries across the regions), programmes with patient safety element(s) included (eg, maternal health programmes in India, pharmacovigilance programmes such as the Pharmacovigilance Programme of India, national transformation programmes such as the Health Sector Transformation Plan in Saudi Arabia’s Vision 2030) and standards (eg, WHO accreditation standards). Patient safety policies were facilitated through accountability (eg, awareness of the need for healthcare improvement and awareness of patient safety through serious incidents), advancements in health policy (eg, during the COVID-19 pandemic), leadership and national-level regulations. Policy development was considered to be impeded as a result of limited community acceptance, lack of research (eg, inadequate reporting and learning), leadership (eg, lack of healthcare leader engagement and accountability), lack of legislation, lack of patient participation, policy challenges, political instability, limited resources and systems challenges.
A large range of initiatives were categorised into distinct areas including accreditation, community engagement, education, events, guidelines, health facility/clinical initiatives, national reporting, patient engagement, research and stewardship. Each of these areas included multiple specific activities, with health facility/clinical level containing the largest range of initiatives, including the development of hospital governance committees, medication safety initiatives, occupational safety initiatives, the WHO patient safety friendly hospital initiative and safety huddles.
Strengths of patient safety initiatives described by participants included enabling HCW training, with shared learning as a key element, leadership commitment in hospitals, particularly in the private sector, and stakeholder engagement and collaboration. In discussing the strengths of initiatives at facility/clinic level, participants mentioned the development of organisational safety culture and improving accreditation, reporting and building patient-centric models of care. Regarding weaknesses, patient safety initiatives were challenged by a disconnect between health delivery and education, lack of training, implementation gaps, low clinical awareness and buy-in at the facility level, a lack of leadership engagement and low community acceptance. At a systems level, lack of basic health services and competing priorities and initiatives, exacerbated by financial limitations and lack of human resources/expertise were seen as current challenges, alongside a lack of national policy and policy-maker awareness and commitment. In some contexts, political instability was considered a challenge.
Participants noted a variety of future opportunities. At the health facility/clinical level, there could be greater development of a just culture and the design of products, processes, services and environments for safety. Education, including training programmes and fellowships, was considered opportunities alongside improved patient safety reporting and the collection of data to improve research and shared learning. Leadership was considered central to developing patient safety initiatives in the future, alongside improved standards, and developing national and global policies. It was also noted that multistakeholder collaboration will be central, including involving patients and the public, and creating patient safety champions. Future threats include a low leadership commitment and changing leadership, and challenges of integration across the system and a public–private quality gap. These threats are further challenged by resourcing and political instability in some contexts. At the facility level, a lack of reporting culture was considered a threat.
Comparison with existing literature
The patient safety policies and initiatives listed by participants in the research are largely in line with what is already well known globally, though this research was able to capture these in one place and alongside a range of global, regional, and national policies and initiatives that are being used in the Middle East and Asian regions. This work was also able to build on existing research. For example, the 2010 WHO research on global priorities identified inadequate competence and skills training as a priority,19 and as such it is unsurprising that education was a theme raised by participants as a weaknesses in the Middle East and Asian region. However, this research provides greater insights on where the specific challenges lie in the Middle East and Asian regions, specifically a disconnect between health delivery and education, as well as a lack of patient safety training in the health facilities/clinics. Similarly, at the policy level, participants highlighted patient safety policy uses and gaps, but also opportunities to develop patient safety policies in the future through the development of committed leadership, accountability and awareness of the need for healthcare improvement, and learning lessons from serious incidents. Existing research further outlines the value of engaged national leadership, specifically, Ministries of Health, in enabling patient safety initiatives in the Middle East.20
Focusing on the SWOT analysis, a lack of appropriate knowledge and transfer identified in the WHO research resonates with participant views that there are future opportunities to develop research and stakeholder engagement to advance patient safety initiatives. SWOTs related to health facility/clinical initiatives have also been widely reported on in existing studies. Organisational safety culture, for example, has been widely researched internationally as an important aspect of driving safer care, although evidence on the link between safety culture and patient outcomes is scarce.21 Alshammari et al found that nurse–patient communication barriers in Saudi Arabia had implications for patient safety.22 Kodate et al note that healthcare practitioners in Japan were more likely to use incident data to improve patient safety where professional siloes were reduced, psychological burden was addressed, leadership showed a duty of care to junior staff, and educational and innovative models to reporting incidents in hospital and community care were embraced.23 The centrality of leadership at all levels of the system in realising future opportunities or posing threats was a clear theme identified through the SWOT analysis, again mirrored in academic and grey literature focused on facilities/clinics,24 25 as well as national policy.26 27
Implications for research, policy and practice
Future research should explore the development of policies and initiatives for patient safety at the provider, local and national levels to build up more nuanced findings that can inform action in each of these areas of the health system. Such research would advance knowledge on the current challenges and future threats identified by our research participants and enable quality and safety improvements across the regions and countries of the Middle East and Asia. The research highlighted some of the complex systems challenges associated with quality and safety improvements in some countries and regions. For example, human resource and financial constraints were noted in almost all settings, but some participants highlighted the threat of political instability in limiting advancement of the patient safety agenda. Urgent research is required to explore the impact of political instability, particularly the frequent changing of political leadership, on patient safety policies and initiatives, and how negative impacts can be mitigated to drive stable advancement of safety and quality.
Previous research highlighted engaged leadership across different levels of the system, as such a key area of need for further investigation is how to develop sustained engagement at Ministry of Health, local government and provider organisations. Mechanisms in engaging leaders will likely differ across these levels of the system, and so, developing a joint up approach to leadership engagement, including capacity building, will be essential in developing policies and initiatives for patient safety in the long term. The value of undertaking regional research enables the development of shared learning and best practice examples and case studies. For example, the qualitative approach taken enabled participants to outline positive examples in specific country contexts, including in Oman and Pakistan, that can be expanded on to provide regional best practice examples for others.
The importance of multistakeholder engagement in driving advancement in developing and implementing patient safety policies and initiatives was clearly expressed in the focus groups. However, the patient perspective is a key aspect missing from this research, and this must be embedded in further research and policy development. National and local policy-makers must ensure they engage with relevant stakeholders, including patients and the public, in developing patient safety policies, while providers must seek to develop codesign methodologies and receive feedback from patients, families and caregivers when implementing patient safety initiatives in the healthcare setting. A top-down and bottom-up approach to patient and public engagement in safety and quality will strengthen policies and initiatives to bring benefits back to stakeholders and the wider system.
As such, key priorities for research and policy are:
Conduct research on the impact of political instability on patient safety priorities and initiatives.
Research on the impact of political instability, particularly the frequent changing of political leadership, on patient safety policies and initiatives, and how negative impacts can be mitigated will drive stable advancement of safety and quality.
Develop a joint-up approach to leadership engagement
Developing a joint up approach to leadership engagement, including capacity building, will be essential in developing policies and initiatives for patient safety in the long term.
Translate research findings into actionable shared learning and best practice examples
Undertaking regional research to enable the development of shared learning and best practice examples will encourage others to pursue tried and tested approaches.
Engage patients and the public in policy-making and implementation of initiatives
National and local policy-makers must ensure they engage with relevant stakeholders, including patients and the public, in developing patient safety policies, while providers must seek to develop codesign methodologies and receive feedback from patients, families and caregivers when implementing patient safety initiatives in the healthcare setting.
Strengths and limitations
The research study offers a snapshot and insights into patient safety policies and initiatives across the Middle East and Asian regions. Such information is particularly important in understanding where health systems and providers are developing patient safety approaches, where gaps remain and critically, what future opportunities can be capitalised on to improve patient safety outcomes. A key strength of the study is the range of participants who attended the focus groups, as we were able to capture diverse observations and viewpoints. These individuals were from countries across the Middle East and Asia regions and represented academia, national and regional systems, and health facility leadership across public and private institutions. Semistructured interviews also enabled the multidisciplinary research team to gain nuanced insights from participants.
A primary limitation of the study is the relatively low number of participants given the regional scope of the research. However, the research was designed to explore the topic at a high level, providing a snapshot of information, rather than an in-depth exploration within and across countries. The self-selection of study participants is another limitation as the sample and their reflections may not be representative of all patient safety experts in the regions. Individuals with an interest in patient safety were more likely to agree to take part in the study, so their experiences with patient safety policies and initiatives may be more extensive, therefore, possibly causing the findings to have some bias towards stronger opinions on patient safety priorities. Similarly, as 52.3% of participants were from one country (Pakistan), results may also be biased towards the patient safety priorities nationally in Pakistan. However, as several themes were universally noted by all participants in the research and no themes raised were excluded, the bias should be minimal. Finally, conducting the focus groups online via Microsoft Teams may have excluded participants who were unable to attend online meetings due to individual requirements/preferences or infrastructure challenges (eg, limited network connectivity).
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
Ethics statements
Patient consent for publication
Ethics approval
The study protocol was approved by the Imperial College Research Ethics Committee (ICREC) (no. 22IC7427).
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors NO'B, MS, ZA and MD conceptualised the manuscript. MS, NO'B and AS undertook the focus groups. NO'B, MS, AS, KL and YW completed the data analysis. NO'B and MS co-lead on the administration and writing of the original draft with support from AS. All authors equally contributed to the writing, reviewing and editing. ZA and MD supervised the work. All authors contributed to and approved the revisions. NO'B is responsible for the overall content as guarantor.
Funding Infrastructure support was provided by the National Institute for Health Research (NIHR) North West London Patient Safety Research Collaborative.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.