By Ehi Iden, CEO Occupational Health and Safety Managers, Ikeja Lagos, Nigeria
Across the world, healthcare leaders and stakeholders have launched a number of initiatives to improve patient safety and eliminate preventable harm within healthcare facilities. A number of goals have been set and several sustainable actionable plans have been designed. The initiatives, plans and goals are impressive, and we are hoping they can transcend to healthcare systems across Africa and particularly in Nigeria where I am domiciled.
Healthcare facilities were not originally designed to harm patients. They should be a place where patients receive care and empathy to heal the body, mind and soul. In the words of Florence Nightingale, “the very first requirement of a hospital is that it should do the sick no harm.” This is a clear mandate to both the stakeholders who sit on boards and to the caregivers who care for patients. We are all collectively responsible for ensuring that patients return home to their loved ones unharmed.
This mandate can become reality only when leadership commits to patient safety and positive patient outcomes – and this is where we largely get it wrong in Africa as a government and as a people. From my experience, a culture of safety is the bedrock for eliminating preventable harm in hospitals.
One of the concerns is that our hospitals do not give due consideration to the safety and health of caregivers. This box has long been left unchecked and this shortcoming correlates to negative impacts on the safety of patients. For example, most hospitals do not have procedures that consider the vaccination profile of healthcare employees. Some healthcare workers have existing health concerns when they are employed, which leads to infecting the patients they manage. Compulsory vaccination of the employees should start at recruitment. This would give staff some relief knowing he or she is covered against certain preventable infections.
We have to address the healthcare work schedule in Nigeria. Most healthcare systems have two shifts of 10–12 hours each. This leads to exhausted workers and tired workers make mistakes. These schedules are set for a couple of reasons: either the hospital does not want to pay more in wages to have the appropriate number of healthcare workers or there is a shortage of healthcare workers.
The lack of a safety culture is also responsible for certain situations in which there are no documented work procedures or processes to ensure patient or staff safety. In most cases, we see different processes being used by different healthcare workers in the same facility, this is both frightening and intolerable; and leads to poor patient outcomes.
We also have a high rate of surgery site infections and injuries. Most are never reported or documented so we can learn from them, and they are never disclosed to the patients or their families. This immense absence of honesty of care goes against the principles of communication and optimal resolution (CANDOR). Patients that get infections experience longer hospital stays and they are still made to pay for the extended admission for a problem that was caused by the healthcare system. This happens daily in healthcare facilities here.
There is a shortage of healthcare professionals in Africa and most countries in Sub-Saharan Africa have few qualified doctors or nurses. Some hospitals are even forced to train young secondary school leavers as nurses. This has given rise to a high number of unregistered providers with professional councils and are never guided by any code of practice.
The latest data from the World Health Organization (WHO) reveals that Nigeria’s Physician-to-Patient ratio is 4 doctors to 10,000 patients. Compare that to countries like Qatar, which has 77 physicians to 10,000 population. According to the 2014 WHO report, Nigeria has only 150,000 registered nurses for a population of 160 million, a ratio of 1 nurse to 1,006 people. The WHO standard is 22 nurses to 10,000 population. In Nigeria, we train and graduate healthcare professionals, but they do not stay to practice due to our poor healthcare infrastructures and discouraging remuneration.
Poor healthcare funding is another key issue. Nigeria’s annual healthcare budget is less than 4 percent of the National Budget, public hospitals are not funded even for the right drugs or diagnostic equipment, let alone investment in training and integrating patient safety into behaviors and systems. This leads to a poor infection management system and poor levels of disinfection and sterilization. Personal protective equipment needed by healthcare workers are insufficient, we lack hand sanitizers, and most times there is no running water for caregivers to wash their hands after handling patients. I have witnessed a nurse, during delivery with a failed suction machine, use her mouth to suck the mucous from the baby’s airway because that was all she could do, at risk to herself and the infant patient.
A number of hospitals are even allowed to operate without regulatory registration. In these facilities, patients are harmed on a daily basis without any reporting. This is where the government has absolute responsibility. Patient safety has to be at the front line of healthcare discussions and our national agenda.
We need to look at things differently. First, we need to look at the healthcare system as a workplace before seeing it as a place in which we seek care. Then let’s consider safe processes as part of the infrastructure of healthcare facilities, the spaces have to be designed to reduce patient harm. We need to review the increasing number of hours in healthcare shifts, accidents will surely happen through overwork and overdraw of healthcare workers. We need to start creating a culture of incident reporting and give assurances that we will not be blamed. Then we can use the incident as a learning moment.
Most importantly, we need to improve our healthcare infrastructure and increase our healthcare budget. Without these two factors, patient safety and good treatment outcomes will only be a dream. In the WHO Abuja Declaration (2001), it was agreed that healthcare funding should be increased to at least 15 percent of the National Budget. Most countries across Africa, including Nigeria, have yet to acknowledge or meet this agreement.
We need to start the dialogue now so we can make these critical changes and begin to save lives.