Perioperative learning in Africa

Operating theatres are a high-risk area in every country but in parts of Africa where infrastructure, equipment and staff are in short supply, they are particularly risky. Information on the risks is rarely available as there are scarce opportunities for training. Since 2002, Friends of African Nursing (FoAN) has been delivering training on patient and staff safety to perioperative nurses in various countries. We find that participants in our training are often surprised and alarmed at what we share with them. 

Through face-to-face education, and more recently webinars, we deliver training on infection prevention, patient safety and how staff can keep themselves safe. Group work on the same topics enables participants to put their own stamp on future practice back at their individual hospitals, as well as learning from fellow participants. 

How Friends of African Nursing was established

FoAN was conceived by two nurses working in the NHS who had visited hospitals in different African countries and wanted to share their knowledge of how to keep patients safe. The team made its first visit to Uganda in 2002, where one delegate taking part in the training had worked in the operating theatre for 38 years and had never had any ongoing professional education. That first course is memorable as we had asked for a maximum of 50 students and 77 turned up! It was a very crowded teaching room with complicated logistics into the bargain! After that, many other countries asked us to help them with the same update to basic perioperative information. Working through the Ministries of Health or national nursing organisations, we have now worked in 11 African countries. 

The charity is run on a voluntary basis, so there is a limited amount of time we can take away from our paid roles. However, because we still work in clinical settings, the training we deliver is up to date and in line with international best practice. Each visit usually lasts a week and we spend each day delivering education to eager students. Since the Covid-19 lockdowns, we have run webinars on a regular basis. Although these are better than nothing, they are unsatisfactory as we cannot check understanding. However, recently we have found that the chat button is a helpful way to get feedback and find answers to questions.  

Perioperative teams in Africa

We usually visit capital cities where we are hosted by teaching hospitals and visit their operating theatres at some time during the week. In the early days of FoAN, we made it our business to also visit and teach at rural hospitals, so we could understand the different issues that occur at theatres away from the capital. It has certainly been eye-opening, and we still ensure that the training we do includes delegates from rural areas. 

The country we visited most recently has invited us to specifically train district theatre nurses on our next visit. One issue they face is that some nurses do not undertake much surgery and have hours of inaction. Supplies and equipment are scarce and qualified team members even fewer. The literature shows that sometimes surgery is not available in some district hospitals at weekends and during the night due to lack of staff. Training is unavailable and as the use of surgery increases, as it is doing all over the developing world, these are the teams that need the most input.

Focus on safety

The training programme we deliver focuses on many aspects of patient safety. It is a relatively new academic topic and many theatre nurses have not been educated in initiatives such as WHO’s Safe Surgery Saves Lives. Some hospitals are using the checklist for every surgery if they have a champion clinician, but many are not. When we introduce the topic, citing the data, many of our participants are visibly shocked.  

In 2015, the Lancet Commission on Global Surgery outlined five necessary components to ensure the delivery of safe surgery. These are infrastructure, surgical workforce, service delivery, financing and information management. Capacity building through improved infrastructure and trained surgical workforce expansion has proven to be challenging to sustain on a global scale. (1) One reliable study which is frequently cited is perioperative patient outcomes in the African Surgical Outcomes Study undertaken in 25 different African countries in 2018. Their findings showed that one in five surgical patients in Africa developed a perioperative complication, following which, one in ten patients died. The findings also show that despite the profile of the surgical patients being younger with a low-risk value and lower occurrences of complications, patients in Africa were twice as likely to die after surgery when compared with outcomes at a global level. They reported that most surgical procedures were done on an urgent or emergency basis and one third were caesarean sections. Importantly, ninety five percent of the deaths occurred after surgery, indicating the need to improve the safety of perioperative care. (2) It is critical in the light of this data that surgical care becomes safer and more effective. 

Barriers to patients accessing surgery

There are many barriers to overcome for patients in countries that are upscaling their surgical services. They include fear of surgery, fear of anaesthetic and fear of poor outcomes. It is therefore essential that perioperative staff are able to show confidence in the safety of their service when they meet their patients. 

There are also financial barriers which may prevent patients accessing healthcare. The costs of drugs, dressings, laboratory tests and X-rays are all paid for in many African countries by the patient or their relatives. Hospital stays must also be paid for, as well as food and drink. In addition, the cost of the accompanying caregiver who stays alongside the patient, looking after them when there are too few nurses to do so, must also be covered.  

An understanding of the challenges that patients have in accessing the care they need, helps to make the teaching we deliver a two-way process, so we all learn from each other. It also serves to underline how fortunate we are in the NHS where costs are taken by the taxpayer and all professional healthcare staff can access learning in so many specialities. 

References

1. Meara J, Leather A, Hagander L et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet, 27 April 2015

2. Bicard B, Madiba T, Kluyts L et al. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet, 3 January 2018

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When preventable harm in healthcare occurs, it is not uncommon for patients and family members to feel as though they are alone with nowhere to turn to report, reconcile or recover from the error. Doors close, eyes avert and they are left to pick up the pieces, with the fear that the same error will harm another patient in the near future. That’s exactly what happens to 250,000 Americans each year in US hospitals and healthcare organisations.[1] Unfortunately, despite best efforts, this problem continues to cripple patients, families and caregivers.  

Current experience of patients after medical error

Up until now, if patients experienced a medical error, their options to report it to bodies that could investigate the error and put solutions in place for the future were limited, if they existed at all. Though there have been strides to improve patient safety in the last several decades, medical errors are still too common, patients are still too often excluded from improvement discussions, and errors are reported in siloes across the country. 

Efforts to make significant advancements for patient safety

Given the significant patient safety challenges in the US, a number of healthcare organisations and expert representatives began to call for the creation of the US National Patient Safety Board (NPSB). The US’s NPSB would:

• monitor and anticipate patient safety events using artificial intelligence
• conduct multidisciplinary reviews to understand the causes of errors
• collaborate with existing systems to implement recommendations for improvement. 

The NPSB would ensure a scalable, data-driven and proactive approach to reducing preventable harm in healthcare. The NPSB concept is backed by a long history of attempts to establish a similar system. It now offers a solution to respond to these calls to action and synthesise existing efforts into a national oversight body. Patient and family member involvement will serve as a foundation for NPSB work, to ensure that recommendations from safety investigations are impactful and resonate with the needs of patients and families around the US.

Models from other countries

Other countries have experienced similar problems and have proposed the creation of their own national patient safety investigation bodies. Since implementation, these bodies, among others, have responded to healthcare safety concerns from patients, family members, members of the general public and healthcare staff by conducting formal investigations, proposing recommendations for improvement based on multidisciplinary discussion and widely reporting results for shared learning. These bodies also function as a mechanism to aggregate national patient safety concerns to better detect key themes in previously disparate areas. 

England’s Healthcare Safety Investigation Branch (HSIB) England established the Healthcare Safety Investigation Branch to improve patient safety through investigations for shared learning and improvement that avoid blame and liability. The HSIB philosophy clearly highlights the importance of patient and family engagement in their work. Recognising the differing needs in diverse patient populations, HSIB involves patients and family members in various ways in their national investigations and maternity investigations. Ensuring patients and family members are central to the investigation and proactively providing support are key principles embedded in each HSIB investigation. 

Norwegian Healthcare Investigation Board (NHIB) Norway has established a similar independent government agency called The Norwegian Healthcare Investigation Board to investigate adverse events and other serious concerns involving Norwegian healthcare services. NHIB involves patients and family members as partners in the dialogue throughout their investigations, with the aim of shedding light on gaps and hearing potential recommendations from their perspectives. 

Safety Investigation Authority, Finland (SIAF) Finland’s Safety Investigation Authority examines safety-related accidents across multiple sectors, including aviation, railroad, marine and health and social care. SIAF launches investigations into both individual accidents, as well as safety themes across the nation.

Given the transformative impact these bodies have had on improving safety, members of the NPSB coalition have made an effort to identify and include best practices from these organisations.

How will patients and family members be involved in the NPSB?

The organisations mentioned above have made strides in meaningfully including patients and family members in their investigations. Similarly, the NPSB has embedded stipulations for patient and family involvement into the fabric of the Bill. Specifically, the NPSB will involve patient representatives at the highest levels and ensure patients and family members have a readily-accessible portal to submit patient safety concerns. 

Why is the NPSB pivotal for patients, family members and members of the general public?

Patients, family members and the general public have the most to gain from a NPSB. 

• Firstly, not only will the NPSB act as an independent federal agency, but NPSB representatives will complement existing federal agencies to minimise duplicative work and amplify progress toward actionable solutions. 
• Secondly, the NPSB will offer patients and family members not only a place to report harm in healthcare, but also a seat at the table where the investigations are conducted and solutions are recommended. 
• Finally, the NPSB will accelerate the proactive identification of early indicators of patient safety problems around the nation through the use of robust data collection and artificial intelligence. 

Though some patient and family member representatives advocate for increased transparency and patient and family input in the current text of the Bill, the NPSB is an important first step in achieving safer healthcare and should continue to develop in these areas once established in the future. 

What will happen next with the NPSB? 

The H.R.9377 National Patient Safety Board Act was introduced on 1 December 1 2022 by US Representative Nanette Barragán (D-CA) and is expected to be reintroduced this year in the new Congress, where it will go through Committees in each chamber of Congress for members to research, discuss and potentially make changes. Once both the US House of Representatives and Senate have voted to accept the Bill, any differences will be reconciled and both will vote again. If the Bill passes both Chambers, it will go to the President to sign into law or veto.

What can I do to support the NPSB? 

The NPSB will revolutionise patient involvement in patient safety across the nation. Patients, family members and members of the general public are urged to find out more about the National Patient Safety Board or get involved in supporting the National Patient Safety Board Act by visiting the NPSB website or following NPSB on Facebook or Twitter. 

Related reading

Patient Safety Spotlight interview with Soojin Jun, Co-founder of Patients for Patient Safety US

How would a National Patient Safety Board (NPSB) benefit patients and families? (February 2023)

References

1 Study suggests medical errors now third leading cause of death in the U.S., John Hopkins Medicine, 3 May 2016

Strategic priority 1 - Together with clients and patient

• Increase engagement to improve safety
• Promote client safety and patient safety side by side
• Experiences of clients, patients and close ones guide our service development

Strategic priority 2 - Thriving and competent professionals

• Ensure safety competence and its development throughout careers
• Create safety by supporting wellbeing at work
• Improve safety through active leadership

Strategic priority 3 - Safety first in all organisations

• Open data and information guide our actions and increase safety
• Ensure safe remote and digital services
• Safety culture is the foundation of our daily work

Strategic priority 4 - Enhanced best practices

• Increase medication safety through common practices
• Ensure the safe use of medical devices and information systems
• Harmonise good practices in infection prevention and control

The Strategy states that progress against these priorities and objectives will be monitored by the following ten key indicators:

1. Service organisers are committed to implementing the objectives of the national Client and Patient Safety Strategy in their own strategies and action plans.
2. Service providers have adopted hotline indicators of Never Events as part of their monitoring system.
3. The incidence of healthcare-associated infections (HCAIs) shows a downward trend. 
4. The number of medication-related harm shows a downward trend.
5. Cooperation models have been created between client and patient representatives and service providers and service unit leaders.
6. The contents of the WHO Patient Safety Curriculum are included in the basic training of all healthcare and social welfare professionals.
7. National development work has been launched to increase safety and wellbeing at work among healthcare and social welfare staff.
8. The reporting and learning procedure for safety incidents has been reformed to meet the needs of a changing service system in terms of content and it has been integrated as part of service organisers’ information systems.
9. Monitoring reports on client and patient safety are published annually at the national level and in the wellbeing services counties.
10. Networks promoting client and patient safety cover all stakeholders and geographically the whole country.

1. The paediatric mental health crisis.
2. Physical and verbal violence against healthcare staff.
3. Clinician needs in times of uncertainty surrounding maternal-fetal medicine.
4. Impact on clinicians expected to work outside their scope of practice and competencies.
5. Delayed identification and treatment of sepsis.
6. Consequences of poor care coordination for patients with complex medical conditions.
7. Risks of not looking beyond the "five rights" to achieve medication safety.
8. Medication errors resulting from inaccurate patient medication lists.
9. Accidental administration of neuromuscular blocking agents.
10. Preventable harm due to omitted care or treatment.

Recurrent Patient Safety Challenges

Over the years, the following patient safety concerns have made repeat appearances on ECRI’s list of Top 10 Patient Safety Concerns; the list begins with the most frequently mentioned:

• Medication safety
• Diagnostic stewardship and test result management
• Behavioural health
• Health IT
• Detecting changes in patient condition
• Workforce staffing, skills, and safety
• Culture of safety and the infrastructure for safety
• Device cleaning, disinfection, and sterilization
• Medical devices and supplies
• Telehealth and digital health
• Care fragmentation and poor care coordination
• Antimicrobial stewardship
• Emergency preparedness
• Infection prevention and control
• Health equity
• Patient identification

Significant improvement in patient safety is possible by empowering patients and healthcare professionals through people-driven, collaborative and sustainable approaches.

EPSF mission

To improve patient safety in Europe by:

• empowering people for patient safety.
• developing innovative, meaningful, sustainable and replicable patient safety projects.
• creating a European multidisciplinary platform for exchanging knowledge and best practices.
• promoting and stimulating application of best practices that lead to longlasting changes in safety culture in healthcare.

EPSF values

• People Focus: We believe that development of safer healthcare system is only possible whenever we listen, empower, and support healthcare workers and patients.
• Collaboration: European, multi-specialty collaboration is essential to achieve sustainable improvement of patient safety in Europe.
• Ethics: Integrity, honesty, mutual respect and clear ethical rules are crucial for the establishment of long-lasting partnerships.
• Driving for quality: Anything we do, we do it well.

• Track trends in patient satisfaction and contribute to a highly reliable health system in Kenya.
• Contribute to quality of care through sustained multi-sectorial partnerships.
• Promote the resolution of medical negligence incidences between the patients and the healthcare service provider(s).
• Contribute to policies, guidelines and legislative measures for delivery of healthcare in Kenya.
• Contribute to the provision of advisory and legal support services to patients and their kin.
• Empower patients on their rights and roles to information at the healthcare facilities.
• Representation of the interests of the public into Boards, Commissions and Committees on health subjects.
• Accelerate uptake of the promotive, preventive, curative, rehabilitative and palliative health services in Kenya.
• Contribute to the institutional and public education on emerging issues in health.

See the attachment for further information about COFPAK.