Unique factors affecting patient safety in humanitarian environments

As a nurse and quality of care advisor for Médecins sans Frontières / Doctors Without Borders (MSF), I know how challenging it can be to minimise healthcare-related risks in humanitarian settings. Medication supplies are disrupted when borders close or roadways are blocked by fighting. Patients delay care due to insecurity or unreliable transportation resulting in serious illness, and care complexity increases the occurrence of patient safety incidents. The health workforce shrinks with forced displacement that compounds health worker shortages already suffering from lack of investment in educational infrastructure. The built environment becomes less safe as investments for health facility infrastructure maintenance are diverted to crisis response. The voice of our patients is silenced as their care options diminish.

However, many elements of safe healthcare systems can transcend borders and care disruptions due to crisis. Institutionalising quality of care requires us as aid workers to challenge our ways of thinking and working.

Keeping patient safety at the forefront

Healthcare needs in humanitarian crises are overwhelming and prioritising services within overlapping, urgent needs is extremely challenging. An emergency response mentality – needed and appropriate during crisis – may also encourage us to favour access to care over quality. It can be tempting to deprioritise the mundane elements of patient safety in favour of urgent care provision and programme growth. We must navigate this tension and walk the line between emergency response and systems building that minimises risk as much as possible. This can be easier said than done.

Building and maintaining systems which support safe care delivery as part of humanitarian medical aid requires the following:

1. Humanitarian healthcare leaders who are engaged and committed to developing and maintaining a positive patient safety culture that is routed in patients’ needs are crucial. They must keep patient safety in the conversation, while at the same time working to respond to emergency situations or growing programming to meet evolving needs. It is essential that they express this commitment in organisational strategies and investment in the building blocks of safe systems, such as quality monitoring to measure clinically relevant and actionable indicators, collected not for reporting to leadership or donors but with the expectation to learn and improve. Staff development on patient safety and quality improvement is an additional requisite component, especially when healthcare workers do not benefit from this in their clinical curricula.

2. Systems to support learning from unsafe care across a range of environments are needed for ongoing learning and decreased risk to patients.

One common aspect of patient safety systems – incident reporting – must be tailored to the realities of humanitarian healthcare. Reporting systems need to be accessible to frontline workers without complex technology or internet connectivity. Incident data collected must capture not only clinical aspects of care delivery, but also the situational factors, such as supply chain disruption that can drive poorer outcomes during crises. More importantly, humanitarian workers must be empowered to speak up when safety issues compromise patient care, without fear of blame or judgment.

3. Aid organisations, including MSF, work in support of Ministries of Health and must be flexible. As more countries develop national strategies for quality of care and patient safety, aid organisations must be ready to support their implementation. In some environments, this may mean bolstering local systems, such as national incident reporting systems or monitoring tools. In others, it may be appropriate to replace an inadequately developed system or one that is unable to function due to the humanitarian context. The onus of doing both is on MSF and our peer organisations.

4. We must also adapt so-called 'best-practices' to different cultural environments. For example, patient advisory committees are often cited as an important part of patient safety assurance. In some settings, this may mean recruiting patients to participate on boards; this will necessarily look different in a place where traditional leaders speak for their communities or when relying on written communication may exclude community members from engagement.

Everyone deserves safe care

These suggestions probably sound familiar. Indeed, many are the basic components of patient safety programmes around the world. Keeping patients safe in humanitarian settings requires many common investments, but with adaptation to meet the unique challenges to safe care delivery.

Everyone, and especially the children and neonates who are the focus of this year’s World Patient Safety Day events and who comprise a significant portion of the people we serve, deserves to receive safe care. It’s up to us as aid workers to challenge our beliefs, our practices and our care processes and build a healthcare system that supports this right.

The history of the civil war in Sudan goes back to the birth of the modern, post-colonial nation. Its sparks erupted in the year 1955 in southern Sudan, with demands for political and human rights in the southern region. Since that date, the country has experienced many internal wars, including the outbreak of this last war on 15 April 2023 in the Sudanese capital, Khartoum. This latest fighting has been fuelled by vertical and horizontal divisions in the Sudanese Armed Forces and paramilitary groups, which have been the tool of this chronic war. As a result of the war, the institutions of the country have gradually abandoned their functional role, and this is seen especially with regard to the provision of healthcare services. 

During this latest war, many of the health service’s institutions have gone out of service, either due to the lack of equipment and the loss and shortage of healthcare professionals, or because of direct targeting by both sides of the conflict. This targeting is a clear violation of all local and international norms and laws, and means the Sudanese healthcare system faces tragic conditions. It has lost its ability to adapt to bear the burdens of this war throughout the country, and the war has exposed medical teams, first aid teams and emergency committees to many risks related to their own safety. And because patient safety relies on the safety of medical teams, the provision of safe medical services has been disrupted.

I have been observing the impact on the health system throughout this latest war, and can see that from the top of the health system management hierarchy, there has been an absence of management. Government institutions lack adequate plans to manage this disaster. Some of the biases and limitations that are associated with power have also had an impact on how the health system has fared.

But there is hope. In spite of these challenges, the Sudan Medical Association—represented by its executive committee, its branches in the states, its general assembly and its emergency groups— has displayed leadership and provided a practical alternative that has contributed to the management of healthcare during the conflict. It has been able to organise and direct the healthcare system to adapt to the disaster of the war.

According to the latest report of the Sudan Medical Association and its Preliminary Committee, which was issued on 1 June 2023:

• 66% of hospitals adjacent to war zones are out of service
• out of (89) basic hospitals in the capital and the states, there are (59) suspended hospitals and (30) hospitals that are fully or partially functioning (some of them provide first aid only.
• many hospitals are threatened with closure due to the lack of medical staff, medical supplies, water and electricity, 

According to another report dated 12 June 2023, the number of civilian deaths reached 958, in addition to about 1,000 other deaths in Western Sudan that are not included in the report, and the number of casualties is 4,746. These numbers do not include deaths and injuries among soldiers on both sides of the war. 

Here are my observations about the impact of war on patient safety:

• The collapse of leadership, administrative systems and communication management systems has a direct impact on case management, which impacts patient safety.
• War makes it more difficult for the population to find and access medical and health services. Often, patients cannot be safely and appropriately transported to healthcare facilities.
• During a war, the quality of healthcare services deteriorates, for example in areas such as infection control and patient falls. Communication between medical teams becomes more difficult. 
• Identifying injured patients and those who have died is very challenging and  large numbers remain unidentified. The accumulation of bodies in the roads leads to environmental risks. 
• The collapse of the primary healthcare sector and related services increases patient safety risks for key groups of patients. It becomes harder to follow-up with pregnant women and people with chronic diseases and disabilities.
• Immunisation services and childhood vaccinations are interrupted and  infectious disease and environmental health services cannot fully function, which may lead to emergence of epidemic outbreaks.
• Lack of availability of medicines, diagnostic and therapeutic medical devices increases the risks to patient safety.
• Medical staff shortages become much worse. In Sudan there is an acute shortage of medical staff in areas including orthopaedics, general surgery and emergency doctors.

Further blogs from Dr Ahmed Khalafalla:

• Spotlight on Sudan: How can we improve healthcare services during war?

• Screen all new entrants, including children, for tuberculosis (TB).
• (Due to low prevalence) look for hepatitis B risk factors that may indicate a need for screening.
• Consider screening for hepatitis C (considerably higher prevalence than the UK).
• There is a risk of typhoid infection.
• Consider nutritional and metabolic concerns.
• Work with a professional interpreter where language barriers are present.
• Consider the impacts of culture, religion and gender on health.
• Assess for mental health (and trauma) conditions.
• Support individuals and ensure that all patients, especially children, are up-to-date with the UK immunisation schedule, including making the offer of Covid vaccination (primary course, boosters, or completion of initial course if begun overseas)
• Refer pregnant women to antenatal care.
• Newly arrived individuals will need help on how to access the NHS, and this will include GP registration as the principle route for accessing services.

Individuals may struggle to provide proof of ID, address or confirmation of immigration status and their registration requests should be managed sensitively. None of these documents are required for registration and the inability of any individual to provide them is no reason to refuse registration.

Relevant tools and resources are listed under five areas:

• ensuring access and basic infrastructure for quality
• shaping the system environment
• reducing harm
• improving clinical care
• engaging and empowering patients, families and communities.

Cross-cutting products are also signposted. The compendium is a companion to the World Health Organization resource Quality of care in fragile, conflict-affected and vulnerable settings: taking action.