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In this blog, Dr Ahmed Khalafalla looks at the war in Sudan and its disastrous consequences for the health system. He outlines his observations about the impacts of war and conflict on patient safety, from shortages of medical equipment to disruptions to vital primary care services. War is the worst thing a person can experience. 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?

Patients falling (falling, slipping) is considered one of the most important patient safety risks in the elderly, in health institutions (hospitals, health centres..., etc.) in particular, and more generally in daily life activities at home, out shopping, etc. In this article I call for a cultural transformation for avoiding falls: from a culture of patient safety that focuses on falls within health facilities to a wider societal culture that must be adhered to by all members of society to prevent the risks of falling in the elderly and other groups at high-risk (including those with specific diseases, disabilities due to congenital causes, accidents...). In this article, I explore what we mean by patients falling, what the consequences are and what we should do to prevent the risks of falling. What is patient falling? Simply, the patient falling is defined as the patient falling to the ground, whether from a bed or chair or while walking, which can be caused by many factors. What are the causes of falls? Falls can happen for a number of reasons, many of the causes are common and there are many factors that can frequently increase the risk of falling in health facilities or outside them: Reasons related to the person or the patient, such as some health conditions, dizziness, poor vision, general weakness, being older and many other pathological injuries, are considered to increase the risk of the patient falling. Reasons related to the environment surrounding the patient or the person at risk of falling; these reasons are many, including those related to the surface of the floor on which the patient walks, surfaces that cause sliding, the absence of lighting or low lighting, the presence of moveable obstacles, whether furniture or other, the absence of installed supports such as handles on doors, etc. General reasons related to natural factors, climate and disasters. Fall risk Fall injuries are considered one of the highest patient safety risks and the most costly in health facilities or in the community where the effects of falls can be monitored according to the severity of the fall. Some simple falls may not produce injuries, but they pose a risk to the patient. Falling is one of the threats to the safety of patients inside health facilities but also poses a safety threat in the community for people at risk of falling. Falls can increase the burden of an already longstanding disease and/or cause an additional sickness burden to the patient as a result of serious injuries caused by the fall, such as head injuries, bone fractures and wounds. The severity of the injury varies and is affected by other factors, such as age and the nature of the fall itself. It can cause an increase in hospitalisation and the length of stay in hospitals and may extend the risk of permanent disability, which in turn is a high economic cost on individuals and families and public spending budgets. Fall prevention Prevention of patient falls has become a priority in health facilities as a requirement of healthcare quality and patient safety. Most healthcare systems have developed policies and implemented procedures and evaluation tools to reduce and prevent patient falls, designing and adapting their systems accordingly. One such tool is the Morse tool, which is a performance tool used to assess a patient's risk of falling (weak, medium or high) and thus taking measures or interventions according to the patient’s condition to prevent falls. There are many safety interventions to prevent the risk of falling, including: positioning of the floors so that they are designed to prevent slipping placing anti-slip tools in bathrooms and rooms, as well as non-slip carpets if they do not hinder movement using sticks placing alarm devices and emergency bells for patients to call for help paying attention to lighting reviewing the health status of a person at high risk of falling and monitoring them periodically, especially those with eyes and visual acuity disorders review the condition of lenses or glasses close monitoring of patients with chronic diseases and other pathological conditions such as permanent disability, whether congenital or acquired. Conclusion Although the prevention of patient falls is an international patient safety goal in health facilities, in this article I wanted to highlight a general call for community attention to the problem of falls as it is one of the general safety risks that endanger the safety of millions of people in homes, roads, workplaces, markets and transportation. As well as a public responsibility to take care of it in order to avoid its short and long-term effects and complications, and its high health, social and economic costs, it is also an early warning bell for health authorities to take care of patient safety issues related to patient falls.

Early-years, primary and secondary education services have been severely affected by the global Covid-19 pandemic. As a result, school healthcare services have also been affected in terms of accessibility and the flow of services. In this blog, Dr Ahmed Khalafalla looks at the effects of this disruption to education-based health services. During the Covid-19 pandemic, schools around the world were closed as part of infection control measures to try and stop the spread of the virus. Many schools and education systems adapted by moving to e-learning using distance learning platforms. The secondary impact of school closures on school healthcare But school closures had other effects, including disrupting school healthcare services. Around the world, lockdown measures disrupted preschool check-ups, vaccinations, screening programmes and health education activities in schools. This new mode of education also had a significant impact on the psychological and social health of students and their parents. For children with learning disabilities, the impact was even greater as they could not access specialist health and therapeutic services they would normally receive in school. The challenges of in-person education during the pandemic As countries made progress in controlling Covid-19, there was a gradual return to normal life activities in many countries. But challenges arose for students as they returned to their schools, some of which were caused by the infection prevention and control measures needed to ensure a safe return to the classroom. Schools needed to strictly monitor the epidemiological situation and carry out risk assessments, and were under a large amount of scrutiny. Alongside education activities, school health services gradually started to function again, but they also had to make adjustments to ensure they were adhering to infection control measures. Although technology can be used to replace some manual systems, some services still need direct human interaction, especially those related to medical procedures. Schools are well placed to deliver healthcare services and public health measures School healthcare services remain vital for public health as they benefit the physical and mental health of students and have an impact on their educational performance. These services therefore have an impact on the future health of societies and influence future generations' views of healthcare quality and patient safety. I think we need to give more support and attention to school healthcare issues - schools have a unique opportunity to be encouraging and supportive places for students, and a setting for social health interventions and community participation programs. They are well placed to identify and meet the needs of their students, parents and communities.

In this personal narrative, Dr Ahmed Khalafalla describes his experience of the Covid-19 pandemic as a general practitioner in Saudi Arabia. He describes new mental health issues that he has witnessed in his clinic as a result of infection prevention and control measures, and asks questions about the ongoing impact of the pandemic on the health needs and behaviour of the general population. I have worked as a general practitioner in a family clinic for 11 years and have noticed a number of changes in patient presentation since the start of the Covid-19 pandemic. Since the outbreak of Covid-19, I have seen a significant increase in the number of seasonal flu cases compared to the previous three years, despite good coverage from the seasonal flu vaccine. I reviewed about 2,500 to 4,000 cases associated with seasonal flu and upper respiratory tract infections. These numbers would have been remarkable, before Covid-19. The Covid-19 outbreak was reported in Wuhan, Central China in December 2019 and in March 2020 was classified by the World Health Organization as a global pandemic. Most countries began emergency infection control procedures to prevent the virus from spreading, which significantly restricted and changed daily life for much of the world’s population. These emergency measures were accompanied by extensive media coverage about the virus, with different and sometimes conflicting information about the disease being shared through multiple different media channels. There was little scientific knowledge about the nature of the disease, how it affects patients and the epidemic trajectory. We also lacked specific treatments for Covid-19, did not understand the efficacy of preventative measures and at that point did not have vaccinations. Numbers of deaths were being shared around the world on a continuous basis. However, in our community we did not have a high death rate, so this information did not provide a helpful local picture for my patients. Many misunderstood the statistics and definitions. All of these factors have produced a state of anxiety in society, which has had a direct effect on the cases I see in my clinic. I have already reviewed multiple cases of Covid-phobia, delusion about having Covid and Covid-related anxiety. These psychological symptoms are sometimes accompanied by behaviours that disrupt people’s lives such as obsessive disinfection and social divergence. These behaviours have grown from the infection-control culture that has developed during the crisis of the pandemic. Medical systems have become a more significant power in decision making during the pandemic. We now need to use this influence to reassure people in the community and help them adjust to life on the other side of the pandemic. We need to offer psychological support to those who have suffered as a result of lockdown restrictions. The question that preoccupies me is “What will life be like after the end of this pandemic?” Will people return to how they lived before Covid-19, or have there been fundamental changes that have occurred to their lifestyle? Have we moved further towards a life that is more virtual than real, with e-health, online education, online shopping and banking, and communication via social media? What will the psychological and behavioural changes be for people? How do we treat the issues that will arise as a result? How will clinics look in the future, and what knowledge do we need to support this change? How will our health systems will need to change to accommodate this new way of living?