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journal.pone.0204801.pdf
RESEARCH ARTICLE
Perspectives of healthcare professionals in
Qatar on causes of medication errors: A
mixed methods study of safety culture
Derek StewartID 1*, Binny Thomas1,2, Katie MacLure1, Abdulrouf Pallivalapila2, Wessam El
Kassem 2 , Ahmed Awaisu
3 , James S. McLay
4 , Kerry Wilbur
3 , Kyle Wilby
3 , Cristin Ryan
5 ,
Andrea Dijkstra 6 , Rajvir Singh
6 , Moza Al Hail
2
1 School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom, 2 Women’s
Hospital, Hamad Medical Corporation, Doha, Qatar, 3 College of Pharmacy, Qatar University, Doha, Qatar,
4 Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom, 5 School of Pharmacy,
Royal College of Surgeons in Ireland, Dublin, Ireland, Dublin 2, 6 Hamad Medical Corporation, Doha, Qatar
Abstract
Background
There is a lack of robust, rigorous mixed methods studies of patient safety culture generally
and notably those which incorporate behavioural theories of change. The study aimed to
quantify and explain key aspects of patient safety culture which were of most concern to
healthcare professionals in Qatar.
Methods
A sequential explanatory mixed methods design of a cross-sectional survey followed by
focus groups in Hamad Medical Corporation, Qatar. All doctors, nurses and pharmacists
were invited to complete the Hospital Survey on Patient Safety Culture (HSOPS). Respon-
dents expressing interest in focus group participation were sampled purposively, and dis-
cussions based on survey findings using the Theoretical Domains Framework (TDF) to
explain behavioural determinants.
Results
One thousand, six hundred and four questionnaires were received (67.9% nurses, 13.3%
doctors, 12.9% pharmacists). HSOPS composites with the lowest levels of positive
responses were non-punitive response to errors (24.0% positive) and staffing (36.2%). Spe-
cific TDF determinants potentially associated with these composites were social/profes-
sional role and identity, emotions, and environmental context and resources. Thematic
analysis identified issues of doctors relying on pharmacists to correct their errors and being
reluctant to alter the prescribing of fellow doctors. There was a lack of recognition of nurses’
roles and frequent policy non-adherence. Stress, workload and lack of staff at key times
were perceived to be major contributors to errors.
PLOS ONE | https://doi.org/10.1371/journal.pone.0204801 September 28, 2018 1 / 17
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OPEN ACCESS
Citation: Stewart D, Thomas B, MacLure K,
Pallivalapila A, El Kassem W, Awaisu A, et al.
(2018) Perspectives of healthcare professionals in
Qatar on causes of medication errors: A mixed
methods study of safety culture. PLoS ONE 13(9):
e0204801. https://doi.org/10.1371/journal.
pone.0204801
Editor: Susan Hrisos, Newcastle University,
UNITED KINGDOM
Received: June 30, 2017
Accepted: September 15, 2018
Published: September 28, 2018
Copyright: © 2018 Stewart et al. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All quantitative data
derived from the cross-sectional survey are given
in the paper. For the focus group discussions, data
are qualitative in nature and cannot be made
publicly available due to ethical as they contain
potentially identifiable information. Researchers
who meet the criteria for access to confidential
data may contact the Robert Gordon University
Research Ethics Sub-Committee, Research-
Conclusions
This study has quantified areas of concern relating to patient safety culture in Qatar and sug-
gested important behavioural determinants. Rather than focusing on changing behaviour at
the individual practitioner level, action may be required at the organisational strategic level
to review policies, structures (including resource allocation and distribution) and processes
which aim to promote patient safety culture.
Introduction
Promoting patient safety in healthcare settings is a global challenge, with an estimated one in
ten patients being harmed whilst receiving care [1]. In an effort to raise awareness of key con-
cepts and strategies in patient safety, the World Health Organization (WHO) published ‘Medi-
cation Without Harm, WHO Global Patient Safety Challenge’ in March 2017 [2,3]. The
challenge calls for action to reduce patient harm which occurs as a result of unsafe medication
practices and medication errors [2,3]. The goal is to ‘gain worldwide commitment and action
to reduce severe, avoidable medication-related harm by 50% in the next five years, specifically
by addressing harm resulting from errors or unsafe practices due to weaknesses in health sys-
tems’. Accumulation of evidence confirms that healthcare professionals often prescribe, dis-
pense and administer medication in ways and circumstances that may increase the risk of
patient harm [4–8].
Whilst it is noted that the magnitude and nature of medication harm may differ between
countries, globally the cost associated with medication errors has been estimated at US$ 42 bil-
lion annually [2,3]. The most commonly cited and accepted definition of the term ‘medication
error’ is that of the National Coordinating Council for Medication Error Reporting and Pre-
vention (NCCMERP) in the United States (US), ‘any preventable event that may cause or lead
to inappropriate medication use or patient harm, while the medication is in the control of the
health care professional, patient, or consumer’ [9]. Most research literature focuses on errors
relating to prescribing, administration and dispensing, with evidence that causation is often
complex and multifactorial. Systematic reviews have focused on causes of medication errors in
different patient populations and settings [10–13]. Common to all systematic reviews is the rel-
atively poor research methodologies reported in most of the primary literature, a lack of beha-
vioural theory and organisational culture in study design. Furthermore, very few studies
employed a mixed methods approach to allow quantification and in-depth description and
explanation of contributory factors.
Behavioural theories may be used to provide explanation hence providing a robust and rig-
orous foundation for development of behaviour change interventions. The United Kingdom
(UK) Medical Research Council (MRC) framework, ‘Developing and implementing complex
interventions’ highlights the importance of considering theory, noting that interventions
grounded in theory are more likely to be effective than those developed empirically or prag-
matically’ [14]. The Theoretical Domains Framework (TDF) is being used increasingly within
health-related research to provide insight into influences on behaviour. TDF derives from 33
psychological theories and 128 theoretical constructs organised into 14 domains of behavioural
determinants, as described in Table 1 [15].
It is apparent that there is also a need to focus attention on organisational safety culture.
The ‘Study Group on Human Factors’ defines organisational safety culture as, ‘the product of
individual and group values, attitudes, perceptions, competencies, and patterns of behaviour
Perspectives of healthcare professionals in Qatar on causes of medication errors
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Funding: This publication was made possible by
NPRP grant NPRP 7-388-3-095 from Qatar
National Research Fund (a member of Qatar
Foundation). The statements made herein are
solely the responsibility of the authors.
Competing interests: The authors have declared
that no competing interests exist.
that determine the commitment to, and the style and proficiency of, an organization’s health
and safety management [16].’ While two systematic reviews have explored interventions to
promote safety culture in hospitals in general and acute hospitals specifically, medication safety
was not a feature of any primary research [17,18].
In an attempt to promote and standardise the measurement of organisational safety culture,
the US Agency for Healthcare Research and Quality (AHRQ) and Medical Errors Workgroup
of the Quality Interagency Coordination Task Force (QuIC) sponsored the development of the
Hospital Survey on Patient Safety Culture (HSOPS) [19]. Items are clustered within 12 com-
posites as presented in Table 2.
Research on medication errors within the Middle East has historically been reported
to be of poor quality [20]. Recently, Elmontsri et al. conducted a systematic review to
explore the status of patient safety culture in Arab countries based on the findings of the
HSOPS [21]. Data from 18 studies across seven countries (excluding Qatar) were
included, identifying that composites relating to non-punitive response to error to be
infrequently practised in their organisation, that staffing levels were often inadequate
and that communication needed to be more open. The authors concluded that further
research is warranted to provide explanation of these findings and to identify potential
interventions to enhance culture and patient safety.
The aim of the present study was to quantify and explain key aspects of patient safety cul-
ture which were of most concern to health professionals in Qatar.
Table 1. Description of TDF domains (adapted from Cain et al. [15]).
TDF Domains Description
Knowledge An awareness of the existence of something
Skills An ability or proficiency acquired through practice
Social/Professional Role and
Identity
A coherent set of behaviours and displayed personal qualities of an individual in
a social or work setting
Beliefs about Capabilities Acceptance of the truth, reality, or validity about an ability, talent, or facility that
a person can put to constructive use
Optimism The confidence that things will happen for the best or that desired goals will be
attained
Beliefs about Consequences Acceptance of the truth, reality, or validity about outcomes of a behaviour in a
given situation
Reinforcement Increasing the probability of a response by arranging a dependent relationship,
or contingency, between the response and a given stimulus
Intentions A conscious decision to perform a behaviour or a resolve to act in a certain way
Goals Mental representations of outcomes or end states that an individual wants to
achieve
Memory, Attention and Decision
Processes
The ability to retain information, focus selectively on aspects of the environment
and choose between two or more alternatives
Environmental Context and
Resources
Any circumstance of a person’s situation or environment that discourages or
encourages the development of skills and abilities, independence, social
competence, and adaptive behaviour
Social Influences Those interpersonal processes that can cause individuals to change their
thoughts, feelings, or behaviours
Emotion A complex reaction pattern, involving experiential, behavioural, and
physiological elements, by which the individual attempts to deal with a
personally significant matter or event
Behavioural Regulation or
measured actions
Anything aimed at managing or changing objectively observed
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Methods
Study design
A sequential explanatory mixed methods design was employed, with a cross-sectional survey
followed by focus groups in samples of questionnaire respondents to provide further depth
and explanation of survey findings [22,23].
Setting
The research was conducted within Hamad Medical Corporation (HMC), the main provider
of secondary and tertiary healthcare in Qatar.
Cross-sectional survey
The first phase of the research was a cross-sectional survey.
Questionnaire development
The questionnaire was adapted from AHRQ HSOPS with items presented as 5-point Likert
type scales; personal and practice demographic items were added. The common language of
care delivery at HMC is English thus translation into other languages (e.g. Arabic) was not
required. The questionnaire was piloted in a convenience sample of 100 healthcare profession-
als. Test-retest reliability was assessed in pilot respondents by requesting that the questionnaire
be completed on a second occasion within an interval of two weeks. A high level of test-retest
Table 2. HSOPS composites and definitions [19].
Composite Definition: The extent to which. . .
Communication openness staff freely speak up if they see something that may negatively affect a
patient and feel free to question those with more authority
Feedback and communication about
error
staff are informed about errors that happen, are given feedback about
changes implemented, and discuss ways to prevent errors
Frequency of events reported mistakes of the following types are reported: mistakes caught and corrected
before affecting the patient; mistakes with no potential to harm the patient;
and mistakes that could harm the patient but do not
Handoffs and transitions important patient care information is transferred across hospital units and
during shift changes
Management support for patient
safety
hospital management provides a work climate that promotes patient safety
and shows that patient safety top priority
Non-punitive response to error staff feel that their mistakes and event reports are not held against them and
that mistakes are not kept in their personnel file
Organisational learning—continuous
improvement
mistakes have led to positive changes and changes evaluated for
effectiveness
Overall perceptions of patient safety procedures and systems are good at preventing errors and there is a lack of
patient safety problems
Staffing there are enough staff to handle the workload and work hours are
appropriate to provide the best care for patients
Supervisor/manager expectations and
actions promoting patient safety
supervisors/managers consider staff suggestions for improving patient
safety, praise staff for following patient safety procedures, and do not
overlook patient safety problems
Teamwork across units hospital units cooperate and coordinate with one another to provide the
best care for patients
Teamwork within units staff support each other, treat each other with respect, and work together as
a team
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reliability was achieved (p<0.001, Cohen’s kappa) for all Likert statements. The final question-
naire was formatted in Snap 10 Professional (software for web and email questionnaire design,
publication, data entry and analysis). On completion of the questionnaire, respondents were
invited to participate in focus groups to discuss responses in more detail.
Recruitment
All doctors, nurses and pharmacists working within HMC were eligible to participate, with no
exclusions. Three hundred and sixty responses were required to give a margin of error of 5%
with 95% confidence intervals [24]. Online participation was encouraged via HMC web alerts
and promotional posters; paper-based questionnaires were distributed to all doctors, nurses
and pharmacists. Data were collected from mid-January 2016 to mid-April 2016.
Data analysis
Anonymised online submissions were imported into Snap before direct export to SPSS version
21.0 and data cleaned prior to analysis. Paper-based questionnaire data were entered manually
using the survey link. Descriptive statistics were used to describe respondents’ demographic
and professional characteristics as well as their responses to individual HSOPS safety culture
items. For each composite, a score was determined in line with the recommendations of the
AHRQ task force [19]. This involved firstly calculating the percentage of positive responses to
each item. A positive response may reflect agreement with a positively phrased statement, or
may reflect disagreement with a negatively phrased statement. Therefore, for positively worded
items the percentage of positive responses is the proportion of ‘agree’ and ‘strongly agree’
responses to the item, and for negatively worded items the percentage of positive responses is
the proportion of disagree and strongly disagree responses to the item. Higher percentages (%)
therefore reflect more positive responses to HSOPS safety culture items as defined in Table 2.
The composite score was then expressed as the mean of the positive responses. For those com-
posites with overall positive responses of <50%, Chi-square was used to determine any statisti-
cally significant associations with demographic variables.
Focus groups
To clarify, explore and explain issues identified in the survey phase, a qualitative approach was
employed.
Sampling and recruitment
Respondents of the survey who expressed interest in participating in the focus groups were
sampled purposively to represent a range of professions, hospitals and number of years of
experience.
Data generation
The focus group topic guide was developed following analysis of the questionnaire data, with
reference to the TDF [15]. Initial discussions were based around views and experiences on
safety culture in relation to causes of medication errors. This was followed by targeted discus-
sions around patient cases of errors illustrating errors in prescribing, dispensing and adminis-
tration in diverse patient groups which led to significant harm. TDF domains were used as
prompts in relation to potential causes of errors. Focus groups were moderated by two experi-
enced qualitative researchers, with informed consent obtained from each participant at the
outset. Discussions were audio-recorded (with permission), transcribed verbatim and checked
Perspectives of healthcare professionals in Qatar on causes of medication errors
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for transcribing reliability. A clear audit trail was maintained which documented details of
data gathering to promote dependability [25]. Sampling and recruitment continued to the
point of data saturation, when no new themes emerged from data analysis [26]. Focus groups
were conducted between mid-May 2016 and mid-June 2016.
Data analysis
Data analysis followed the Framework Approach, using TDF domains deductively for to gen-
erate a coding framework [27]. Two researchers independently read each focus group tran-
script repeatedly to ensure familiarity, then coded text to one or more TDF domains. Any
disagreements were resolved by discussion which involved a third researcher if needed.
Ethics
The study received ethical approval from Hamad Medical Corporation, Medical Research
Center Qatar, Qatar University Institutional Review Board and Robert Gordon University
Research Ethics Sub-Committee. Return of the questionnaire was taken as an indication of
informed consent; written informed consent was obtained from all focus group participants.
Results
Cross-sectional survey
Respondents’ demographics and professional characteristics. One thousand, six hun-
dred and four completed questionnaires were received, with most (67.9%) from nurses fol-
lowed by doctors (13.3%) and pharmacists (12.9%). Around three quarters (70.9%) were
female, <40 years (76.0%) and almost half (48.1%) with more than 10 years of experience as
healthcare professionals. Respondents had varying involvement with medicines-related pro-
cesses as follows: prescribing medicines (15.1%); administering (61.1%); preparation and dis-
pensing (25.9%); and monitoring (42.0%) (Table 3).
Patient safety culture items. Positive responses to the HSOPS composites and items are
given in Table 4. Composites with the lowest levels of mean positive responses were: non-puni-
tive response to errors (24.0%); staffing (36.2%); communication openness (50.5%); handoffs
and transitions (53.1%); and supervisor/manager expectations and actions promoting patient
safety (56.5%). Composites with the highest levels of positive responses were: organisational
learning–continuous improvement (85.5%); team working within unit (82.1%); and manage-
ment support for patient safety (75.4%). For the two composites with mean positive responses
of <50%, Chi-square was used to determine the associations between percentage positive
responses and demographics/professional characteristics.
Non-punitive response to errors—all individual items contributing to this HSOPS compos-
ite attracted a low level of positive response, this was particularly the case for items relating to
staff concerns over errors being kept in their personnel files (26.2%), and the perception that
errors counted against them (14.6%). There were highly statistically significant associations
with mean composite agreement and gender (females most positive, Χ2 (1, N = 1547) = 8.23, p<0.005), age (older most positive, Χ2 (4, N = 1555) = 11.62, p<0.05) and experience as a healthcare professional (the most experienced being most positive, Χ2 (5, N = 1536) = 18.42, p<0.005).
Staffing–while all responses attracted a low level of positive response, this was particularly
the case for work pressures and speed of work (23.5%). There were highly statistically signifi-
cant associations with mean composite agreement and healthcare professions (doctors most
positive and pharmacists least, Χ2 (2, N = 1494) = 42.06, p<0.001), age (youngest least and
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Table 3. Respondents’ demographic and professional characteristics (N = 1604).
Characteristic Percentage Frequency, n
Current role in the hospital Clinical nurse educator 0.7 12
Clinical pharmacist 2.8 45
Consultant physician 5.4 86
Head/Charge/Specialist nurse 17.1 275
Nurse 50.0 802
Pharmacist 8.9 143
Pharmacy Director/Supervisor/Specialist 1.2 19
Resident Physician 3.5 56
Specialist Physician 4.5 72
Other 5.0 80
Missing 0.9 14
Age (years) �29 24.2 392
30–39 41.8 670
40–49 21.5 345
50–59 9.5 153
�60 1.6 25
Missing 1.7 19
Gender Male 27.6 442
Female 70.9 1137
Missing 1.6 25
Countryof receiving entry-to-practice degree India 42.7 685
Philippines 17.6 283
Egypt 9.3 149
Qatar 9.2 148
Jordan 4.8 77
Other 14.5 231
Missing 1.9 31
Experience as healthcare professional in hospital (years) <1 1.6 25
1–5 19.1 306
6–10 29.4 471
11–15 21.4 343
16–20 12.0 193
>20 14.7 235
Missing 1.9 31
Experience as healthcare professional in Qatar (years) <1 8.5 136
1–5 40.3 647
6–10 21.8 350
11–15 16.5 264
16–20 5.1 82
>20 6.7 108
Missing 1.1 17
(Continued)
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oldest most positive, Χ2 (4, N = 1564) = 28.89, p<0.001) and experience as a health profes- sional (positive responses increasing with experience, Χ2 (1, N = 1550) = 42.06, p<0.001).
For those ten composites with higher mean agreement, several items had less than half
responding positively. There were issues around: supervisors/ managers overlooking recurring
patient safety problems (31.9% positive); that it was due to chance that serious errors did not
occur (36.0%); problems occurring when exchanging information across hospital units
(42.9%); staff being able to ask questions if things did not seem right (44.0%); that at particular
pressure points supervisors/ managers wanted staff to work faster, even if this required short-
cuts to be taken (46.1%); and staff feeling able to question those in positions of authority
(46.6%).
More detailed data on the responses to individual items within each composite are given in
S1 File.
Focus groups
Demographics of participants. Two hundred and ninety-five survey respondents
(18.4%) expressed interest in participating in focus groups. Nine focus groups were conducted
(duration 45–60 minutes), at which point data saturation was deemed to have been achieved.
Fifty-four individuals from different disciplines participated, with just under half (n = 26,
48.1%) being nurses, followed by 18 (33.3%) pharmacists and 10 (18.5%) doctors. Most were
highly experienced with only 11 (20.4%) having <5 years of experience. During the focus
groups, there was wide-ranging discussion across the spectrum of medication errors of pre-
scribing, administration and dispensing.
Behavioural determinants associated with errors. Themes and subthemes relating to
safety culture identified during focus group discussions are mapped to TDF behavioural deter-
minants, with illustrative quotes provided for each.
A. Social/professional role and identity (a coherent set of behaviours and displayed per-
sonal qualities of an individual in a social or work setting)
Table 3. (Continued )
Characteristic Percentage Frequency, n
Hours worked in a typicalweek <20 1.3 21
20–39 10.6 170
40–59 82.7 1326
�60 3.0 48
Missing 2.4 39
In your role you typically have direct interaction or contact with patients Yes 85.6 1373
No 9.0 145
Missing 5.4 86
Your primaryroles in the medicinesprocess are (multiple optionscould be chosen) Prescribing 15.1 243
Administering 61.1 980
Preparation and Dispensing 25.9 415
Monitoring 42.0 673
Missing 3.1 49
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Table 4. Positive responses to HSOPS items and composites (N = 1604).
Statements % positive response
(100% representing the highest positive
response to each statement)
Non-punitive responseto errors, overall positive response = 24.0%�� �Staff feel like errors count against them 26.2 (disagreed)
�When an error is reported, it feels like the person is being reported,
not the problem
31.1 (disagreed)
�Staff worry that errors they make are kept in their personnel file 14.6 (disagreed)
Staffing, overall positive response = 36.2% We have enough staff to handle the workload 54.7 (agreed)
�We use more locum staff than is best for patient care 30.5 (disagreed)
�We work under pressure trying to do too much, too quickly 23.5 (disagreed)
Communication openness, overall positive response = 50.5% Staff will speak up freely if they see something that may negatively
affect patient care
60.9 (agreed)
Staff feel free to question the decisions or actions of those with more
authority
46.6 (agreed)
�In this unit, staff are afraid to ask questions when something does
not seem right
44.0 (disagreed)
Handoffs and transitions, overall positive response = 53.1% �Things get missed when transferring patients from one unit to
another
53.7 (disagreed)
�Important patient care information is often lost during shift changes 60.8 (disagreed)
�Problems often occur in the exchange of information across hospital
units
42.9 (disagreed)
�Shift changes are problematic for patients in this hospital 55.1 (disagreed)
Supervisor/managerexpectationsand actionspromoting patient safety, overall positive response = 56.5% My supervisor/ manager says a good word when he/she sees a job
done according to established patient safety procedures
73.0 (agreed)
My supervisor/ manger seriously considers staff suggestions for
improving patient safety
74.9 (agreed)
�Whenever pressure builds up, my supervisor/ manager wants us to
work faster, even if it means taking shortcuts
46.1 (disagreed)
�My supervisor/ manager overlooks patient safety problems that
happen again and again
31.9 (disagreed)
Frequency of eventsreported, overall positive response = 58.1% When an error is made, but is noticed and corrected before affecting
the patient, how often is this reported?
53.5 (agreed)
When an error is made, but has no potential to harm the patient,
how often is this reported?
56.9 (agreed)
When an error is made that could potentially harm the patient but
does not, how often is this reported?
63.8 (agreed)
Overallperceptions of patient safety, overall positive response = 59.1%
Patient safety is never sacrificed to get more work done 70.6 (agreed)
Our procedures and systems are good at preventing errors from
happening
78.7 (agreed)
�It is just by chance that more serious mistakes don’t happen around
here
36.0 (disagreed)
�We have patient safety problems in this unit 51.3 (disagreed)
Feedback and communication about error, overall positive response = 61.9% We are given feedback about changes put into place based on error
reports
55.8 (agreed)
(Continued)
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1. Doctors reliance on pharmacists to correct errors. During discussion, it emerged that
there were instances where doctors would rely on pharmacists to correct their prescribing
errors and this led to complacency around prescribing,
‘Yes. Most of the physicians make a medication error and wait for the pharmacist to correct it.’ (Focus Group [FG] 5 Pharmacist 4)
2. Doctors reluctance to alter other doctors’ prescribing. During one focus group, there
was concern that doctors were unwilling to alter prescriptions written by other doctors, partic-
ularly for doctors from other specialities. The doctors considered this to be the responsibility
of the original prescriber, even if a prescribing error had been made and initial prescriber was
unavailable,
‘This will happen when you’re in the Ob-Gyn [obstetrics and gynaecology] setup. If one physi- cian came from Hamad from other. . . from cardiac or other site, if they write any prescription, if you call the Ob-Gyn doctor here, the on duty doctor, she will never agree to change because
Table 4. (Continued )
Statements % positive response
(100% representing the highest positive
response to each statement)
We are informed about medication errors in this unit 62.0 (agreed)
In this unit, we discuss ways to prevent medication errors from
happening again
68.0 (agreed)
Teamwork across units, overall positive response = 67.7% There is good cooperation among hospital units that need to work
together
72.9 (agreed)
Hospital units work well together to provide the best care for patients 82.8 (agreed)
�Hospital units do not coordinate well with each other 57.5 (disagreed)
�It is often unpleasant to work with staff from other hospital units 57.5 (disagreed)
Management support for patient safety, overall positive response = 75.4% Hospital management provides a work environment that promotes
patient safety
87.0 (agreed)
The actions of hospital management show that patient safety is a top
priority
84.2 (agreed)
Hospital management seems interested in patient safety only after an
error happens
54.9 (agreed)
Teamwork within units, overall positive response = 82.1% People support one another in this unit 81.1 (agreed)
When a lot of work needs to be done quickly, we work as a team to
get the work done
83.4 (agreed)
In this unit, people treat each other with respect 81.9 (agreed)
Organisational learning—continuous improvement, Overall positive response = 85.8%
We are actively doing things to improve patient safety 90.2 (agreed)
After we make changes to improve patient safety, we evaluate their
effectiveness
81.3 (agreed)
�Reverse scored negatively worded statement
�� Calculated from the mean items within each composite
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she will say it’s an order from the consultant from cardiology or neurology.’ (FG7 Pharmacist 4)
3. Lack of recognition of the role of nurses. Some of the nurses described that they were
often omitted from discussions around patient care and decision making, even when present
on ward rounds or meetings. There were instances where discussions took place in a different
language,
‘Even I’m noting that during the rounds, team decisions, the nurses are not informed. Some- times they [the doctors] are discussing in Arabic. The nurse, she cannot understand their plan and what is the decision.’ (FG3 Nurse 1)
4. Policy non-adherence. Health professionals not adhering to various policies was con-
sidered a cause of medication errors,
‘Not abiding the. . . complying with the policies’ (FG2 Doctor 2)
‘There are seven or eight points that the pharmacist should check. If the pharmacist, for exam- ple, dispensed the wrong medication it means that he didn’t follow the policy.’ (FG5 Pharma- cist 4)
B. Emotions (a complex reaction pattern, involving experiential, behavioural, and physio-
logical elements, by which the individual attempts to deal with a personally significant matter
or event)
1. Stress leading to medication errors. Stress and high pressure situations were described
in all focus groups as influences on medication errors. While workload was a common factor
leading to stress, patients themselves could also put undue pressure and hence stress of health
professionals,
‘And I think that probably the stresses of the work [lead to errors].’ (FG1 Doctor 2)
‘And parents are too tense than they are. . . even the parents they are too much angry. Yeah, they will scold the staff then like that time they will get pressure.’ (FG7 Nurse 3)
C. Environmental Context and Resources (any circumstance of a person’s situation or
environment that discourages or encourages the development of skills and abilities, indepen-
dence, social competence, and adaptive behaviour)
Much of the discussion centred on aspects of environmental context and resources as key
influences leading to medication errors. These were discussed by all participants in all focus
groups. There were several key themes within this domain.
1. Workload issues leading to medication errors. Workload issues were discussed by
doctors, nurses and pharmacists. Doctors believed one of the reasons for errors to happen was
the heavy workload that they had.
‘Too many patients. Labour ward is full, you know, too many patients for the residents to see.’ (FG1 Doctor 2)
‘Yeah, I’m working in emergency. So what I feel is it’s too much. . . sometime it is too busy and doctors are giving too much orders. . .they cannot to cope with the situation.’ (FG1 Nurse 1)
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One pharmacist noted that the excessive workload for the doctor can lead to errors occur-
ring and that this workload also put pressure on other health professionals which could com-
pound errors.
‘There are two problems here, a load on the physician that can lead to many mistakes and a load on the pharmacist because he needs to dispense medication for this patient and at the same time answer the questions of physician, nurses.’ (FG5 Pharmacist 4)
One of the nurses also explained that the main cause of errors committed by junior medical
staff was workload rather than lack of knowledge.
‘And this is why the medication errors are also increasing, so it’s not always related to the knowledge of the resident. And if the resident is overloaded because he has to document for all the patients and see all the patients and he is receiving calls from other units as well’ (FG3 Nurse 3)
2. Lack of staff at key times. Closely related to workload issues was a critical lack of staff
at key times such as weekends and evening which could compromise patient safety.
‘On the whole days of the week, there is complete staff, complete number of physicians. In weekend, well, only one physician is doing the whole work.’ (FG4 Doctor 2)
‘Especially the areas like emergency, less staff. They will be get. . . too tense by the patients and they just want to do the things for faster. so it will make errors. (FG2 Nurse 1)
3. System-related issues. Discussion also centred on key issues related to the systems in
operation in various wards and departments. There was particular concern over the imple-
mentation of Cerner (electronic health record system for hospitals, health care providers, clin-
ics) from doctors, nurses and pharmacists.
‘The electronic system is not robust, and I mean, the hardware is not good enough.’ (FG2 Doc- tor 1)
‘We have now to concentrate on the mistakes or medication errors happening by the prescrib- ing system.’ (FG5 Pharmacist 2)
One senior doctor commented that following implementation of Cerner, fewer checks were
being performed compared to the previous paper-based system.
‘Before it was like, when you have the hard copy of medication profile, someone is checking and countersigning. Now in the system, it [checking] is not there as far as I know.’ (FG1 Doc- tor 2)
Themes and subthemes for those behavioural determinants less related to safety culture are
summarised in Table 5.
Discussion
Key findings
Our study of the causes of medication errors in Qatar highlighted that the key composites of
patient safety culture which merit attention are: non-punitive response to errors; staffing;
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communication openness; handoffs and transitions; and supervisor/manager expectations and
actions promoting patient safety. During focus group discussions, specific TDF determinants
suggested as being potentially associated with these composites were: social/professional role
and identity; emotions; and environmental context and resources. Thematic analysis identified
issues of doctors relying on pharmacists to correct their errors and being reluctant to alter the
prescribing of fellow doctors. There was a lack of recognition of nurses’ roles and frequent pol-
icy non-adherence. Stress was perceived to be a major contributor to errors, as was excessive
workload and lack of staff at key times.
Strengths and weaknesses
The mixed methods design is a key study strength providing quantification of results followed
by in-depth explanation. Further strengths are the use of the validated HSOPS tool and embed-
ding psychological behaviour change theory (TDF) within qualitative data generation and
analysis [15,19]. There are, however, several limitations hence findings should be interpreted
with caution. Self-reported questionnaire responses could not be validated and may have been
impacted by response and social desirability biases [22]. While responses were received from
healthcare professionals in all HMC hospitals, these may have been skewed towards females
and nurses hence there are potential issues of lack of generalisability within Qatar and beyond.
Similarly, qualitative findings may not be transferable to other healthcare professionals, set-
tings and countries.
Interpretation
This mixed methods study has contributed to the expressed need for robustness and rigour in
patient safety research within the Middle East [20]. Furthermore, it aligns to the WHO ‘Global
Patient Safety Challenge’ calling for action to reduce severe, avoidable medication-related
harm by 50% in the next five years [2,3]. Whilst the HSOPS questionnaire has been used
Table 5. A summary of TDF domains and themes (less related to culture) relating to causes of medication errors.
TDF Domain Subtheme Illustrative quotes
Knowledge 1. Lack of medication related knowledge ‘So coming to the nursing knowledge regarding the dose. I will never believe they have that
much knowledge about the doses. . .’ (FG1 Doctor 1)
2. Knowledge is limited to a particular
speciality/area
‘If we’re dealing with the general hospital, medicine department they have good orientation
regarding medication, but if you go to ortho [orthopaedics] or surgery, really their knowledge
about medication is very low.’ (FG5 Pharmacist 3)
3. Lack of knowledge attributed to staff
induction
‘Proper induction, you know, they should have proper induction regarding the medication, the
medications that are used, how you do the checking and things like that. Nothing is done.’
(FG1 Doctor 2)
4. Need for continuing professional
development to reduce medication errors
‘There is too much error in this area, they can provide another or a new continuous education
for this field. It’s very important and this can prevent such error.’ (FG7 Nurse 1)
Skills 1. Suboptimal medication related skills ‘We need to think about the administration. I have seen plenty of times the paper on which
they [nurses] have written the calculation and it’s wrong, actually most of the time.’ (FG4
Pharmacist 1)
Beliefs about
Capabilities
1. Lack of medication related competence ‘But you think it’s. . . it’s. . . it’s valid to let the nurses check the dose before administering? No,
I don’t think it’s possible. For me, I feel it’s impossible for them to check the correct dose.’ (FG1
Doctor 1)
2. Overconfidence leading to medication errors ‘Overconfidence with some particular medicines like I have been with this medicine for many
years and I know by heart’ (FG1 Pharmacist 2)
Goals 1. Promoting patient safety ‘But you know, serious errors are part of the package, you know. As we save lives, we are not
ensuring. . . I mean, we should expect that we cannot have zero even serious errors because we
are human beings’. (FG5 Pharmacist 1)
https://doi.org/10.1371/journal.pone.0204801.t005
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within the Middle East [21], this is the first study to publish Qatari data. There are, however,
similarities between the Qatari data and those reported by Elmontsri et al. [21], with the lowest
agreement scores (and hence of most concern) relating to the composites of non-punitive
response to errors; staffing; communication openness; handoffs and transitions; and supervi-
sor/ manager expectations and actions promoting patient safety. Within the two composites of
lowest scores (non-punitive response to errors and staffing) there were issues with staff per-
ceiving that errors counted against them and that details of errors committed were kept in
their personnel files. This appeared to be an issue for male, younger and less experienced
healthcare professionals. Staffing was the other key composite with very low agreement scores,
particularly in relation to work pressures and speed of work, with similar statistically signifi-
cant associations as for the non-punitive response to errors. There may be some merit in ini-
tially prioritising any intervention towards these specific groupings.
One limitation of the published studies using the HSOPS is the lack of qualitative research
to provide in-depth explanation of the results [21]. The use of behavioural theory within the
focus groups in this study identified key determinants which could facilitate intervention
development. TDF has been incorporated within intervention developments for smoking ces-
sation, physical activity, hand hygiene, acute low back pain and schizophrenia [28]. To date
only one other published study has applied TDF to explore potential causes of medication
errors, focusing on prescribing errors in a sample of junior doctors in Scotland [29]. There are
some similarities with the findings of this study, most notably within the domains of knowl-
edge and skills, particularly the general lack of medication-related knowledge. While pharma-
cists can provide support, and indeed doctors were found to rely on pharmacists to correct
errors, the HSOPS data and the focus groups identified issues around staff complement and
workload, particularly at key times.
TDF domains of social/ professional role and identify, emotions and environmental context
and resources are related to organisational safety culture, as defined by ‘Study Group on
Human Factors’ [16]. Concerns were expressed around nurses perceiving that their profes-
sional role was not recognised leading to poor communication compromising patient safety.
This is also reflected in the HSOPS score of ~ 50% agreement for communication openness.
There were instances of doctors relying on pharmacists to correct their prescribing errors and,
at times, would not alter the prescribing of others, even when errors could potentially lead to
patient harm. Themes of environmental context and resources also emerged in the discussions
around workload as a leading cause of errors, with lack of staff at key pressure times of evening
and weekends. Furthermore, the electronic prescribing and records system was considered to
have introduced potential for error. While such systems have been shown to enhance patient
safety, others have also highlighted the risky human factors and user-centred design issues that
have been encountered [13].
Stress was the main theme which emerged in the TDF emotions domain as a determinant
of error, arising due to workload, work pressures and the influence of patients. Issues of work-
load were also identified in the HSOPS data around staff numbers to handle the workload,
working under pressure to do too much, too quickly.
These TDF l determinants which were highlighted as potential contributors to medication
errors can be used during the development of behaviour change interventions, defined as
‘coordinated sets of activities designed to change specified behaviour patterns’. These are often
complex, consisting of interacting components known as ‘behaviour change techniques’
(BCTs), ‘observable and replicable components designed to change behaviour’ [30]. Michie
et al. developed a cross-disciplinary taxonomy of evidence based BCTs [31], mapped to specific
TDF domains [32]. Whilst knowledge and skills can be impacted through education and train-
ing [31,32], altering aspects of social/ professional role and identity and environmental context
Perspectives of healthcare professionals in Qatar on causes of medication errors
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and resources are more complex. Indeed, the work of Michie et al. [31,32] did not identify any
evidence-based BCTs which mapped reliably to social/professional role and identity. Those for
environmental context and resources relating mainly to restructuring the physical environ-
ment and providing prompts and cues for safer practice, which in this case would focus on the
electronic medication systems [31,32]. Rather than focusing on changing behaviour at the
individual practitioner level, action may be required at the organisational strategic level to
review policies, structures (including resource allocation and distribution) and processes
which aim to promote patient safety culture and minimise harm. Qualitative research focusing
on understanding the perspectives of key strategic decision-makers in relation to promoting
all aspects of medication safety is warranted.
Conclusion
This mixed methods study has provided further confirmation of key areas of concern relating
to patient safety culture in Qatar. Non-punitive response to errors and staffing had the lowest
levels of agreement, followed by communication openness, handoffs and transitions, and
supervisor/manager expectations and actions. The qualitative component provided further
detail of specific TDF determinants highlighting issues of social/professional role and identity,
emotions, and environmental context and resources. Further attention on these issues at stra-
tegic and policy levels is required.
Supporting information
S1 File. Responses to each of the HSOPS composites.
(DOCX)
S2 File. Study questionnaire.
(DOCX)
Acknowledgments
The authors wish to acknowledge the contributions of all questionnaire respondents and focus
group participants, as well as support departments at Hamad Medical Corporation, Doha,
Qatar.
Author Contributions
Conceptualization: Derek Stewart, Katie MacLure, Abdulrouf Pallivalapila, Ahmed Awaisu,
James S. McLay, Kerry Wilbur, Kyle Wilby, Cristin Ryan, Rajvir Singh, Moza Al Hail.
Data curation: Derek Stewart, Binny Thomas, Katie MacLure, Abdulrouf Pallivalapila, Wes-
sam El Kassem, Ahmed Awaisu, James S. McLay, Kerry Wilbur, Kyle Wilby, Cristin Ryan,
Andrea Dijkstra, Rajvir Singh, Moza Al Hail.
Formal analysis: Derek Stewart, Binny Thomas, Katie MacLure, Abdulrouf Pallivalapila,
Ahmed Awaisu, Kerry Wilbur, Kyle Wilby, Cristin Ryan, Andrea Dijkstra, Rajvir Singh.
Funding acquisition: Derek Stewart, Abdulrouf Pallivalapila, Ahmed Awaisu, James S.
McLay, Kerry Wilbur, Kyle Wilby, Cristin Ryan, Rajvir Singh.
Methodology: Derek Stewart, Binny Thomas, Katie MacLure, Abdulrouf Pallivalapila, Wes-
sam El Kassem, Ahmed Awaisu, James S. McLay, Kerry Wilbur, Kyle Wilby, Cristin Ryan,
Andrea Dijkstra, Rajvir Singh, Moza Al Hail.
Perspectives of healthcare professionals in Qatar on causes of medication errors
PLOS ONE | https://doi.org/10.1371/journal.pone.0204801 September 28, 2018 15 / 17
Supervision: Derek Stewart, Rajvir Singh.
Writing – original draft: Derek Stewart.
Writing – review & editing: Binny Thomas, Katie MacLure, Abdulrouf Pallivalapila, Wessam
El Kassem, Ahmed Awaisu, James S. McLay, Kerry Wilbur, Kyle Wilby, Cristin Ryan,
Andrea Dijkstra, Rajvir Singh, Moza Al Hail.
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