Antibiotic use in acute upper respiratory tract infections and uncomplicated lacerations in the Gaza Strip: clinical audit and re-audit.

BACKGROUND: Overuse of antibiotics is increasing worldwide and has led to a marked increase in multidrug-resistant pathogens. Acute upper respiratory tract infections and uncomplicated lacerations do not require antibiotics. We assessed adherence to the best international standards of antibiotic prescribing for these conditions. METHODS: We did an audit and reaudit at Nasser Hospital in the Gaza Strip. The audit included patients presenting from January to March, 2017, with acute upper respiratory tract infections or uncomplicated lacerations. Random selection, stratified by condition, was used to assign patients to the audit or reaudit. After the audit an action plan was implemented focusing on education of health-care providers and patients for one year. The reaudit was done in 2018, from January to March. Ethics approval was obtained from the Palestinian Ministry of Health. FINDINGS: 240 patients were included overall, 60 with each condition in the audit and 60 with each condition in the reaudit. The 60 patients in the first audit with acute upper respiratory tract infections had a mean age of 32·1 (SD 6·4) years. 25 (42%) had throat examinations, of which 20 (33%) were normal. 52 (87%) of these 60 patients were prescribed antibiotics, which were used by 29 (48%) who cited that they believed it was important to do so. The 60 patients presenting with uncomplicated lacerations had a mean age of 14·5 (SD 10·3) years. Injuries were closed by sutures in 59 (98%) patients, who all received antibiotics. 52 (87%) of 60 patients with lacerations believed that antibiotics accelerate healing. Reaudit after the action plan was implemented showed that antibiotics were prescribed to 43 (71%) patients with acute upper respiratory tract infections (p=0·002) for difference and to 50 (84%) with uncomplicated lacerations. INTERPRETATION: Despite some improvement in appropriate antibiotic use for acute upper respiratory tract infections after hospital-based quality improvement efforts, physicians did not generally follow international guidelines for appropriate antibiotic use and patients believed that their use was important. Development of evidence-based guidelines and education of patients are needed. FUNDING: None.

Undergraduate medical students' attitudes towards medical errors and patient safety: a multi-center cross-sectional study in the Gaza Strip, Palestine.

BACKGROUND: In undergraduate medical education, patient safety concepts and understanding of medical errors are under-represented. This problem is more evident in low-income settings. The aim of this study was to explore undergraduate medical students' attitudes towards patient safety in the low-income setting of the Gaza Strip. METHODS: A cross-sectional, descriptive study included medical students of the two medical schools in the Gaza Strip with 338 medical students completing the Attitudes to Patient Safety Questionnaire-IV (APSQ-IV), which examines patient attitudes in 29 items over 10 domains. Results are represented as means ± standard deviations for each item and domain as well as percentage of positive responses to specific items. RESULTS: Medical students reported slightly positive patient safety attitudes (4.7 ± 0.5 of 7) with the most positive attitudes in the domains of situational awareness, importance of patient safety in the curriculum, error inevitability and team functioning. While no negative attitudes were reported, neutral attitudes were found in the domains of professional incompetence as a cause of error and error reporting confidence. Study year and gender had no significant association with patient safety attitudes, except for disclosure responsibility, where male students displayed significantly more positive attitudes. The study university was significantly associated with three of the 10 examined domains, all of which involved understanding of medical errors, for which students of University 2 (who had undergone limited patient safety training) held significantly more positive attitudes, compared with students of University 1 (who did not have structured patient safety training). CONCLUSION: Medical students' patient safety attitudes were very similar among students from both universities, except for understanding of medical error, for which students, who had received structured training in this topic, displayed significantly more positive attitudes. This underlines the power of the 'hidden curriculum', where students adjust to prevalent cultures in local hospitals, while they do their clinical training. Furthermore, it highlights the need for a systematic inclusion of patient safety content in local undergraduate curricula.

Treating patients in a safe environment: a cross-sectional study of patient safety attitudes among doctors in the Gaza Strip, Palestine.

BACKGROUND: Patient safety is important, as in increasingly complex medical systems, the potential for unintended harm to patients also increases. This study assessed the attitudes of doctors in the Gaza Strip towards patient safety and medical error. It also explored variables that impacted their attitudes. METHODS: Doctors, working for at least 6 months in one of the four major government hospitals of the Gaza Strip, were invited to complete a 28-item, self-administered Arabic version of the Attitudes to Patient Safety Questionnaire III (APSQ-III); which assessed patient safety attitudes over nine domains, independent of the workplace. RESULTS: A total of 150 doctors from four government hospitals participated in this study, representing 43.5% of all 345 doctors working in the four study hospitals at the time of the study. The mean age was 36.6 (±9.7) years. The majority (72.7%) were males, 28.7% worked in surgical, 26.7% in pediatric, 23.3% in medical, 16.7% in obstetrics and gynecology, and 4.7% in other departments. Most participants (62.0%) had never received patient safety training. The overall APSQ score was 3.58 ± 0.3 (of a maximum of 5). The highest score was received by the domain "Working hours as a cause of errors" (4.16) and the lowest score by "Importance of Patient Safety in the Curriculum" (3.25). Older doctors with more professional experience had significantly higher scores than younger doctors (p = 0.003), demonstrating more positive attitudes toward patient safety. Furthermore, patient safety attitudes became more positive with increasing years of experience in some domains. However, no significant impact on overall APSQ scores was found by workplace, specialty or whether the participants had received previous training about patient safety. CONCLUSION: Doctors in Gaza demonstrated relatively positive patient safety attitudes in areas of "team functioning" and "working hours as a cause for error", but neutral attitudes in understanding medical error or patient safety training within the curriculum. Patient safety concepts appear to be acquired by doctors via informal learning over time in the job. Inclusion of such concepts into formal postgraduate curricula might improve patient safety attitudes among younger and less experienced doctors, support behaviour change and improve patient outcomes.

Attitudes of doctors and nurses to patient safety and errors in medical practice in the Gaza-Strip: a cross-sectional study.

OBJECTIVES: This study examined the attitudes of nurses and doctors to key patient safety concepts, evaluated differences and similarities between professional groups and assessed positive and negative attitudes to identify target areas for future training. SETTING: Four major governmental hospitals in the Gaza-Strip. PARTICIPANTS: A convenience sample of 424 nurses and 150 physicians working for at least 6 months in the study hospitals. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measures were mean scores with SD as measured for individual items and nine main patient safety domains assessed by the Attitudes to Patient Safety Questionnaire. Secondary outcome measures were the proportions of doctors and nurses, that gave a positive response to each item, represented as percentage of each group. RESULTS: Nurses and doctors held moderately positive attitudes towards patient safety with five out of nine domain scores >3.5 of 5. Doctors showed slightly more positive attitudes than nurses, despite a smaller proportion of doctors having received patient safety training with 37.5% compared with 41.9% of nurses. Both professions displayed their most positive patient safety attitudes in the same domains ('team functioning' and 'working hours as a cause for error'), as well as their two most negative attitudes ('importance of patient safety in the curriculum' and 'professional incompetence as a cause of error'), demonstrating significant deficits in understanding medical errors. A specific challenge will be the negative attitudes of both professions towards patient safety training for wider dissemination of this content in the postgraduate curriculum. CONCLUSION: Patient safety attitudes were moderately positive in both professional groups. Target of future patient safety training should be enhancing the understanding of error in medicine. Any training has to be motivating and relevant for clinicians, demonstrating its importance in ongoing professional learning.

Patient safety culture among nurses working in Palestinian governmental hospital: a pathway to a new policy.

BACKGROUND: Providing safe care helps to reduce mortality, morbidity, length of hospital stay and cost. Patient safety is highly linked to attitudes of health care providers, where those with more positive attitudes achieve higher degrees of patient safety. This study aimed to assess attitudes of nurses working in governmental hospitals in the Gaza-Strip toward patient safety and to examine factors impacting their attitudes. METHODS: This is a cross-sectional, descriptive study with a convenient sample of 424 nurses, working in four governmental hospitals. The Attitudes to Patient Safety Questionnaire III, a validated tool consisting of 29 items that assesses patient safety attitudes across nine main domains, was used. RESULTS: Nurses working in governmental hospitals showed overall only slightly positive attitudes toward patient safety with a total score of 3.68 on a 5-point Likert scale, although only 41.9% reported receiving patient safety training previously. The most positive attitudes to patient safety were found in the domains of 'working hours as a cause of error' and 'team functioning' with scores of 3.94 and 3.93 respectively, whereas the most negative attitudes were found in 'importance of patient safety in the curriculum' with a score of 2.92. Most of the study variables, such as age and years of experience, did not impact on nurses' attitudes. On the other hand, some variables, such as the specialty and the hospital, were found to significantly influence reported patient safety attitudes with nurses working in surgical specialties, showing more positive attitudes. CONCLUSION: Despite the insufficient patient safety training received by the participants in this study, they showed slightly positive attitudes toward patient safety with some variations among different hospitals and departments. A special challenge will be for nursing educators to integrate patient safety in the curriculum, as a large proportion of the participants did not find inclusion of patient safety in the curriculum useful. Therefore, this part of the curriculum in nurses' training should be targeted and developed to be related to clinical practice. Moreover, hospital management has to develop non-punitive reporting systems for adverse events and use them as an opportunity to learn from them.

Public Awareness and Barriers to Seeking Medical Advice for Colorectal Cancer in the Gaza Strip: A Cross-Sectional Study.

PURPOSE: Raising awareness of colorectal cancer (CRC) symptoms for early recognition, reduction of modifiable risk factors, and removing barriers to seeking medical help could lower its mortality. This study aimed to assess the level of public awareness of CRC in the Gaza Strip. MATERIALS AND METHODS: This was a cross-sectional study conducted at three hospitals and 10 high schools between September and October 2017. The Arabic version of the validated Bowel Cancer Awareness Measure (BoCAM) questionnaire was used to evaluate awareness of CRC symptoms and risk factors, and barriers to seeking medical help. Adults (age ≥ 18 years) in three major hospitals and adolescents (ages 15 to 17 years) in 10 schools were recruited for face-to-face interviews to complete the BoCAM. RESULTS: Of 3,172 potential participants, 3,080 completed the BoCAM (response rate, 97.1%). Among these, 1,578 (51.2%) were adults and 1,614 (52.4%) were females. Persistent abdominal pain was the most commonly recognized CRC symptom (n = 1,899; 61.7%), whereas anorectal pain was the least common (n = 1,056; 34.3%). In total, 2,177 (70.7%) were not confident in recognizing CRC symptoms or signs. Having a bowel disease was the most frequently recognized CRC risk factor (n = 1,456; 47.3%) and diabetes the least recognized (n = 591; 19.2%). The overall mean scores ± standard deviations for recalling and recognizing CRC symptoms were 1.2 ± 1.3 and 4.3 ± 2.3, respectively (out of 9 points). The overall mean scores ± standard deviations for recalling and recognizing CRC risk factors were 0.7 ± 0.8 and 8.0 ± 3.1, respectively (out of 16 points). Emotional barriers were the most commonly reported barriers to seeking medical help, with feeling worried about what a doctor might find as the most common barrier (n = 1,522; 49.4%). CONCLUSION: Public awareness of CRC is suboptimal in Gaza. Improving CRC awareness with educational interventions is needed, including in local schools.

Management of acute ischaemic stroke at Nasser Hospital, Gaza Strip: a clinical audit.

BACKGROUND: Stroke is a leading cause of morbidity and mortality worldwide. The aim of this study was to assess the standard of care for patients with acute ischaemic stroke at the internal medicine department of Nasser Hospital, Gaza Strip. METHODS: For this retrospective clinical audit, we selected a random sample of 100 medical records for patients with stroke who were admitted to Nasser Hospital between January and August, 2016. Clinical practice was compared with the recommendations in the 2013 American Heart Association and American Stroke Association guidelines. Patient confidentiality was maintained, and ethical approval was obtained from the Palestinian Ministry of Health. FINDINGS: Five patient records were not coded and therefore excluded. Of the remaining 95 patients, 51 (54%) were men with a mean age of 67 years (SD 14). 53 patients presented with dysarthria. The duration of stroke symptoms before admission was not reported in 86 (91%) records. A complete blood count and renal function tests were done for all patients, lipid profiling for 87 (92%) patients, electrocardiography for 85 (89%) patients, carotid duplex ultrasound for 32 (34%) patients, and CT scan for all patients. None of the patients had continuous cardiac monitoring or an assessment of swallowing function, and 70 (74%) patients received immediate anti-platelet therapy (325 mg aspirin). 80 (85%) patients received venous thromboembolism prophylaxis. 41 (43%) patients were given antibiotics without a recorded indication. None of the patients received thrombolytic therapy. As recommended in the guidelines, 41 (43%) patients did not receive anti-hypertensive agents on the first day of hospitalisation. 46 (48%) patients had diabetes, and glycaemic control was achieved by day 3 in 26 (57%) patients. INTERPRETATION: No Palestinian guidelines exist for the management of patients with acute ischaemic stroke, and in most cases management was based on personal experience rather than evidence. The development of evidence-based guidelines is mandatory to improve management of ischaemic stroke. Furthermore, implementing staff education activities, regular clinical audit, and team feedback would encourage adherence to such guidelines. Combined with the establishment of a specialised stroke unit and development of a multidisciplinary team approach, patient outcome could be improved further. FUNDING: None.