Health workforce capacity of intensive care units in the Eastern Mediterranean Region.

OBJECTIVE: The onset of COVID-19 pandemic increased the need for functioning and equipped intensive care units (ICUs) with staff trained in operating them. In the Eastern Mediterranean Region, this also triggered the need for assessing the available capacities of ICUs and health workforce so that appropriate strategies can be developed to address emerging challenges of staff shortages in the wake of COVID-19. To address this need, a scoping review on the health workforce capacity of intensive care units in the Eastern Mediterranean Region was conducted. METHODS: A scoping review methodology as outlined by Cochrane was followed. Available literature and different data sources were reviewed. Database includes Pubmed (medline,Plos included), IMEMR, Google Scholar for peer-reviewed literature, and Google for grey literature such as relevant website of ministries, national and international organization. The search was performed for publications on intensive care unit health workers for each of the EMR countries in the past 10 years (2011-2021). Data from included studies was charted, analysed and reported in a narrative format. A brief country survey was also conducted to supplement the findings of the review. It included quantitative and qualitative questions about number of ICU beds, physicians and nurses, training programs as well as challenges faced by ICU health workforce. RESULTS: Despite limited data availability, this scoping review was able to capture information important for the Eastern Mediterranean Region. Following major themes appeared in findings and results were synthesized for each category: facility and staffing, training and qualification, working conditions/environment and performance appraisal. Shortage of intensive care specialist physicians and nurses were in majority of countries. Some countries offer training programmes, mostly for physicians, at post-graduate level and through short courses. High level of workload, emotional and physical burnout and stress were a consistent finding across all countries. Gaps in knowledge were found regarding procedures common for managing critically ill patients as well as lack of compliance with guidelines and recommendations. CONCLUSION: The literature on ICU capacities in EMR is limited, however, our study identified valuable information on health workforce capacity of ICUs in the region. While well-structured, up-to-date, comprehensive and national representative data is still lacking in literature and in countries, there is a clearly emerging need for scaling up the health workforce capacities of ICUs in EMR. Further research is necessary to understand the situation of ICU capacity in EMR. Plans and efforts should be made to build current and future health workforce.

Strengthening hospital resilience in the Eastern Mediterranean Region.

"Adaptation is surviving but resilience is for thriving."In recent years, the multiple threats of COVID-19 and other disease outbreaks, intensified climate change and severe weather events, and increasing conflicts and humanitarian emergencies have highlighted the need to strengthen resilience in the different sectors, including social, economic, environment, and health. Resilience is the ability of a system, community or society exposed to hazards to resist, absorb, accommodate, adapt to, transform, and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions through risk management.

Hospital efficiency in the eastern mediterranean region: A systematic review and meta-analysis.

Background: Recent rising costs and shortages of healthcare resources make it necessary to address the issue of hospital efficiency. Increasing the efficiency of hospitals can result in the better and more sustainable achievement of their organizational goals. Objective: The purpose of this research is to examine hospital efficiency in the Eastern Mediterranean Region (EMR) using data envelopment analysis (DEA). Methods: This study is a systematic review and meta-analysis of all articles published on hospital efficiency in Eastern Mediterranean countries between January 1999 and September 2020, identified by searching PubMed through MEDLINE, Web of Science, Scopus, Science Direct, and Google Scholar. The reference lists of these articles were checked for additional relevant studies. Finally, 37 articles were selected, and data were analyzed through Comprehensive Meta-Analysis Software (v.2.2.064). Results: Using the random-effects model, the mean hospital efficiency in Eastern Mediterranean hospitals was 0.882 ± 0.01 at 95% CI. Technical efficiency (TE) was higher in some countries such as Iraq (0.976 ± 0.035), Oman (0.926 ± 0.032), and Iran (0.921 ±0.012). A significant statistical correlation was observed between the hospital efficiency and the year of publication and sample size (p < 0.05). Conclusion: Efficiency plays a significant role in hospital growth and development. Therefore, it is important for healthcare managers and policymakers in the EMR to identify the causes of inefficiency, improve TE, and develop cost-effective strategies.

A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses.

BACKGROUND: Community health needs and assets assessment is a means of identifying and describing community health needs and resources, serving as a mechanism to gain the necessary information to make informed choices about community health. The current review of the literature was performed in order to shed more light on concepts, rationale, tools and uses of community health needs and assets assessment. METHODS: We conducted a scoping review of the literature published in English using PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library databases until March 2021. RESULTS: A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. Relevant concepts were examined guided by a conceptual framework. The empirical papers were dominantly conducted in the  United States. Qualitative, quantitative and mixed-method approaches were used to collect data on community health needs and assets, with an increasing trend of using mixed-method approaches. Almost half of the included empirical studies used participatory approaches to incorporate community inputs into the process. CONCLUSION: Our findings highlight the need for having holistic approaches to assess community's health needs focusing on physical, mental and social wellbeing, along with considering the broader systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize assessing community health assets as an integral component of the process, beginning foremost with community capabilities and knowledge. There has been a trend toward using mixed-methods approaches to conduct the assessment in recent years that led to the inclusion of the voices of all community members, particularly vulnerable and disadvantaged groups. A notable gap in the existing literature is the lack of long-term or longitudinal-assessment of the community health needs assessment impacts.

Engaging patients in patient safety: a qualitative study examining healthcare managers and providers' perspectives.

BACKGROUND: Patients can play an essential role in improving patient safety by becoming actively involved in their health care. The present study aimed to qualitatively explore healthcare providers' (HCPs) and managers' perceptions on patient participation in patient safety processes. METHODS: This qualitative study carried out in three teaching hospitals in Tehran, Iran. The data were collected through semi-structured interviews with 31 HCPs and managers working at public teaching hospitals, medical universities and the Ministry of Health. The data were analyzed using thematic analysis. RESULTS: Three main themes and 21 sub-themes emerged from the interviews. Participants believed that patients and their families can play an effective role in maintaining and improving patient safety through different roles. However, a variety of barriers were identified at patients, providers, and system levels hindering patient participation in delivering safe care. CONCLUSION: The participants identified facilitators and barriers to patient engagement in safety-orientated activities at multiple patients, providers, and system levels, indicating that complex, multifaceted initiatives must be designed to address the issue. This study encourages further research to enhance the understating of the problems and solutions to patient involvement in safety initiatives in the Iranian healthcare setting.

What is "hospital resilience"? A scoping review on conceptualization, operationalization, and evaluation.

Background: COVID-19 underscored the importance of building resilient health systems and hospitals. Nevertheless, evidence on hospital resilience is limited without consensus on the concept, its application, or measurement, with practical guidance needed for action at the facility-level. Aim: This study establishes a baseline for understanding hospital resilience, exploring its 1) conceptualization, 2) operationalization, and 3) evaluation in the empirical literature. Methods: Following Arksey and O'Malley's model, a scoping review was conducted, and a total of 38 articles were included for final extraction. Findings and discussion: In this review, hospital resilience is conceptualized by its components, capacities, and outcomes. The interdependence of six components (1) space, 2) stuff, 3) staff, 4) systems, 5) strategies, and 6) services) influences hospital resilience. Resilient hospitals must absorb, adapt, transform, and learn, utilizing all these capacities, sometimes simultaneously, through prevention, preparedness, response, and recovery, within a risk-informed and all-hazard approach. These capacities are not static but rather are dynamic and should improve continuously occur over time. Strengthening hospital resilience requires both hard and soft resilience. Hard resilience encompasses the structural (or constructive) and non-structural (infrastructural) aspects, along with agility to rearrange the space while hospital's soft resilience requires resilient staff, finance, logistics, and supply chains (stuff), strategies and systems (leadership and coordination, community engagement, along with communication, information, and learning systems). This ultimately results in hospitals maintaining their function and providing quality and continuous critical, life-saving, and essential services, amidst crises, while leaving no one behind. Strengthening hospital resilience is interlinked with improving health systems and community resilience, and ultimately contributes to advancing universal health coverage, health equity, and global health security. The nuances and divergences in conceptualization impact how hospital resilience is applied and measured. Operationalization and evaluation strategies and frameworks must factor hospitals' evolving capacities and varying risks during both routine and emergency times, especially in resource-restrained and emergency-prone settings. Conclusion: Strengthening hospital resilience requires consensus regarding its conceptualization to inform a roadmap for operationalization and evaluation and guide meaningful and effective action at facility and country level. Further qualitative and quantitative research is needed for the operationalization and evaluation of hospital resilience comprehensively and pragmatically, especially in fragile and resource-restrained contexts.

Health policy analysis in Eastern Mediterranean region using a health policy triangle framework: Historical and ethical insights from a systematic review.

Background: Health policy can be defined as an agreement and consensus on a health-related program and set of actions taken to achieve the goals expected by programs in the area of policy. Policy analysis involves a wide range of methods, techniques, and tools in a way to reach awareness of the impacts of the developed and implemented policies. Whereas policy analysis in developed countries has a long history, in developing countries, it is instead in its first developing stages. Our paper aimed to collect systematically the studies using health policy triangle framework in doing analysis in one of the health policy issues in the Eastern Mediterranean region organization. Methods: To conduct our literature search, ISI/Web of Science, PubMed/MEDLINE, Embase, The Cochrane Library, Global Health Database, Scopus, as well as Google Scholar from 2003 up to June 2020 were systematically mined. To evaluate the methodological quality of the included studies, the Critical Appraisal Skills Program checklist was used. Results: We selected 30 studies, conducted between 2011 and 2020. According to the findings of these studies, in the Eastern Mediterranean region, organization region, and the role of evidence-based research in policy-making has been repeatedly emphasized, but its use in health program decision-making has been limited, and health research systems in Eastern Mediterranean region organization are still under scrutiny. There is still a gap between evidence-based research in health systems and its use in policy-making. Discussion: Based on the present systematic review, studies based on policy analysis should focus on all the elements of health policies and provide evidence to inform decisions that can strengthen health systems, improve health and improve existing inequalities.

Hospitals early challenges and interventions combatting COVID-19 in the Eastern Mediterranean Region.

BACKGROUND: During rapidly evolving outbreaks, health services and essential medical care are interrupted as facilities have become overwhelmed responding to COVID-19. In the Eastern Mediterranean Region (EMR), more than half of countries are affected by emergencies, hospitals face complex challenges as they respond to humanitarian crises, maintain essential services, and fight the pandemic. While hospitals in the EMR have adapted to combat COVID-19, evidence-based and context-specific recommendations are needed to guide policymakers and hospital managers on best practices to strengthen hospitals' readiness, limit the impact of the pandemic, and create lasting hospital sector improvements towards recovery and resilience. AIM: Guided by the WHO/EMR's "Hospital readiness checklist for COVID-19", this study presents the experiences of EMR hospitals in combatting COVID-19 across the 22 EMR countries, including their challenges and interventions across the checklist domains, to inform improvements to pandemic preparedness, response, policy, and practice. METHODS: To collect in-depth and comprehensive information on hospital experiences, qualitative and descriptive quantitative data was collected between May-October 2020. To increase breadth of responses, this comprehensive qualitative study triangulated findings from a regional literature review with the findings of an open-ended online survey (n = 139), and virtual in-depth key informant interviews with 46 policymakers and hospital managers from 18 out of 22 EMR countries. Purposeful sampling supported by snowballing was used and continued until reaching data saturation, measures were taken to increase the trustworthiness of the results. Led by the checklist domains, qualitative data was thematically analyzed using MAXQDA. FINDINGS: Hospitals faced continuously changing challenges and needed to adapt to maintain operations and provide essential services. This thematic analysis revealed major themes for the challenges and interventions utilized by hospitals for each of hospital readiness domains: Preparedness, Leadership, Operational support, logistics, supply management, Communications and Information, Human Resources, Continuity of Essential Services and Surge Capacity, Rapid Identification and Diagnosis, Isolation and Case Management, and Infection, Prevention and Control. CONCLUSION: Hospitals are the backbone of COVID-19 response, and their resilience is essential for achieving universal health coverage. Multi-pronged (across each of the hospitals readiness domains) and multi-level policies are required to strengthen hospitals resilience and prepare health systems for future outbreaks and shocks.

Building resilient hospitals in the Eastern Mediterranean Region: lessons from the COVID-19 pandemic.

Since the COVID-19 pandemic began, hospitals in the Eastern Mediterranean Region (EMR) have faced significant challenges in providing essential services, while simultaneously combatting this pandemic and responding to new and ongoing shocks and emergencies. Despite these challenges, policy-makers and hospital managers adapted their hospital responses to maintain operations and continue providing essential health services in resource-restraint and fragile and conflict affected, offering valuable insights to others in similar contexts. The aim of this paper is to share the lessons learnt from hospital responses to COVID-19 from the EMR. To do this, we triangulated findings from literature review, open-ended online surveys and 46 in-depth key informant interviews from 18 EMR countries. Qualitative findings from semistructured key informant interviews along with the open-ended survey responses resulted in nine major themes for lessons learnt in the EMR. These themes include Preparedness, Leadership and Coordination, Communication, Human Resources, Supplies and Logistics, Surge Capacity and Essential Services, Clinical Management (including Rapid Identification, Diagnosis and Isolation), Infection Prevention and Control, and Information and Research. Each of the nine themes (domains) included 4-6 major subthemes offering key insights into the regional hospital response to health emergencies. Resilient hospitals are those that can provide holistic, adaptable, primary-care-based health systems to deliver high-quality, effective and people-centred health services and respond to future outbreaks. Both bottom-up and top-down approaches are needed to strengthen collaboration between policy-makers, hospitals, front-line workers and communities to mitigate the continued spread of SARS CoV2, build resilient hospital systems and improve public health preparedness and emergency response.

Proactive Innovation in a Prolonged Conflict Setting: Facing COVID-19 in a Specialized Cancer Hospital in Palestine.

The prolonged ongoing conflict in Palestine exacerbated socioeconomic conditions and weakened the health system, complicating the management of COVID-19 pandemic, especially for cancer patients who are doubly-at risk. Augusta Victoria Hospital (AVH) is Palestine's only specialized cancer hospital, receiving patients from the Gaza Strip and the West Bank for oncology, nephrology, hematology, and radiotherapy. AVH's preparedness measures enabled its agile response. These proactive and innovative preparedness measures included: implementing a facility-level preparedness and response plan; utilizing multidisciplinary team-based and evidence-informed approaches to decision making; prioritizing health workers' safety and education; establishing in-house PCR testing to scale up timely screenings; and accommodating health workers, patients, and their relatives at hospital hotels, to maintain daily, continuous and critical health care for cancer patients and limit the spread of infection. At the facility-level, the biggest challenge faced by AVH was continuing essential and daily care for immunocompromised patients while protecting them from potential infection from relatives, hospital staff and other suspected patients. At the national level, the lack of preparedness, inequalities in vaccine distribution, political instability, violence, delays in obtaining medical exit permits to reach Jerusalem, weakened AVH's response. AVH's flexible financing, hospital accreditation, and strong leadership and coordination enabled its agility and resilience. Despite compiling challenges, the hospital's proactive and innovative interventions minimized the risk of infection among two high-risk groups: the immunocompromised patients and their health workers, providing invaluable lessons for health facilities in other fragile-and-conflict-affected settings.

Role of hospital leadership in combating the COVID-19 pandemic.

Hospitals all around the world play an essential role in response to the COVID-19 pandemic. During an epidemic event, hospital leaders frequently face new challenges requiring them to perform unaccustomed tasks, which might be well beyond the scope of their previous practice and experience. While no absolute set of characteristics is necessary in all leadership situations, certain traits, skills and competencies tend to be more critical than others in crisis management times. We will discuss some of the most important ones in this manuscript. To strengthen those managerial competencies needed to face outbreaks, healthcare leaders should be better supported by competency-based training courses as it is more and more clear that traditional training courses are not as effective as they were supposed to be. It seems we should look at the COVID-19 pandemic as a learning opportunity to re-frame what we expect from hospital leaders and to re-think the way we train, assess and evaluate them.

Role of hospitals in recovery from COVID-19: Reflections from hospital managers and frontliners in the Eastern Mediterranean Region on strengthening hospital resilience.

Background: COVID-19 highlighted the critical role that hospitals play throughout the prolonged response and continuous recovery stages of the pandemic. Yet, there is limited evidence related to hospitals in the recovery stage, particularly capturing the perspectives of hospital managers and frontliners in resource-restrained and humanitarian settings. Objective: This paper aims to capture the perspectives of hospital managers and frontliners across the Eastern Mediterranean Region on (1) the role of hospitals in recovering from COVID-19, (2) Hospitals' expectations from public health institutions to enable recovery from COVID-19, (3) the Evaluation of hospital resilience before and through COVID-19, and (4) lessons to strengthen hospital resilience throughout the COVID-19 recovery. Methods: A multi-methods approach, triangulating a scoping review with qualitative findings from 64 semi-structured key-informant interviews and survey responses (n = 252), was used to gain a deeper context-specific understanding. Purposeful sampling with maximum diversity supported by snowballing was used and continued until reaching data saturation. Thematic analysis was conducted using MAXQDA and simple descriptive analysis using Microsoft Excel. Findings: In recovering from COVID-19, hospital managers noted hospitals' role in health education, risk reduction, and services continuity and expected human resource management, financial and material resource mobilization, better leadership and coordination, and technical support through the provision of updated clinical evidence-based information from their public health institutions. Qualitative findings also indicated that hospital managers attributed considerable changes in hospitals' resilience capacities to the pandemic and suggested that strengthening hospitals' resilience required resilient staff, sustainable finance, and adaptive leadership and management. Conclusion: Hospitals are the backbone of health systems and a main point of contact for communities during emergencies; strengthening their resilience throughout the various stages of recovery is critical. Hospitals cannot be resilient in silos but rather require an integrated-whole-of-society-approach, inclusive of communities and other health systems actors.

Agenda-setting of tobacco control policy in Iran: a retrospective policy analysis study.

BACKGROUND: The prevalence of tobacco use, especially hookah, has increased in Iran In recent years, particularly among young people and women, and the age of onset of use has decreased. Tobacco use is the fourth leading risk factor for non-communicable diseases in Iran. These issues cause concerns in the country and led to the present study on tobacco control agenda-setting in Iran over a 30-year timeframe. METHODS: We conducted this retrospective analytical study to investigate process analysis in Iran using Kingdon's multiple-streams framework (MSF). We collected the data using semi-structured interviews with key informants (n = 36) and reviewing policy documents (n > 100). Then, we analyzed the policy documents and in-depth interviews using the document and framework analysis method. We used MAXQDA 11 software to classify and analyze the data. RESULTS: Iran's accession to the Framework Convention on Tobacco Control (FCTC) opened a window of opportunity for tobacco control. The policy window opens when all three streams have already been developed. The adoption of the comprehensive law on the national control and campaign against tobacco in the Islamic Consultative Assembly in 2006 is a turning point in tobacco control activities in Iran. CONCLUSIONS: The tobacco control agenda-setting process in Iran was broadly consistent with MSF. The FCTC strengthened the comprehensive plan for national control of tobacco as a policy stream. However, there are several challenges in developing effective policies for tobacco control in the Iranian setting.

HIV/AIDS policy-making in Iran: A stakeholder analysis.

INTRODUCTION: The present study aims to identify and analyze HIV/AIDS stakeholders in Iran. METHODS: This qualitative stakeholder analysis was conducted in 2018 nationwide, both retrospectively and prospectively. Purposive sampling was applied and followed by snowball sampling until data saturation. Data were analyzed using framework analysis. Also, MAXQDA (Version 11) and Policy Maker software (version 4) was applied. FINDINGS: A total of 44 stakeholders were identified and categorized into 23 active and 21 inactive stakeholders. The Ministry of Education and Iran Broadcasting have moderate participation in this regard. Supreme Council of Health and NGOs have low participation. The Ministry of Health (MoH), State Welfare Organization, Blood Transfusion Organization, and the State Prisons are interested in HIV/AIDS policymaking. The MoH is the main body responsible for the stewardship of HIV/AIDS in Iran but does not have enough authority to handle the issue. CONCLUSION: Considering multidimensional nature of HIV/AIDS, there are many stakeholders regarding HIV/AIDS control. The process of HIV/AIDS -policy making is fragmented in Iran. Despite multiple active and potential stakeholders in this field, there is no integrated system to involve all stakeholders in the process of HIV/AIDS policy-making. Therefore, given the importance of the issue, an upstream entity is needed to coordinate and mobilize all stakeholders associated with managing and controlling HIV/AIDS.

Integrated and People-centred Hospital toward Universal Health Coverage in WHO- European Countries.

Background: Ensuring integrated people-centred health services (IPCHS) that offer universal access, social equity, and financial protection within a primary health care method is important toward universal health coverage and health sustainable development goals. Hospitals are part of this ambitious agenda. The purpose is to review the health system and to list and summarize hospital interventions. Methods: Document review. As part of our review, we selected health systems reports for conceptualizing IPCHS frameworks at the country level as well as those focusing on the hospital sector. Our research team collected and analyzed data including governance, financing, human resource, provision service, and reforms based on the health system report of 14 countries. Results: The review showed 26 challenges, most of which were in Eastern European countries, with 48 interventions in 3 themes and 13 subthemes. Conclusion: Due to the paradigm shift, there is a need for change. However, a much better positive view is needed to determine the role of hospitals in the service delivery system. The IPCHS framework provides guidance for countries in setting priorities, and formulating, implementing, and evaluating national policy/strategic plans for their hospital sector. Although the vision and interventions should be adapted to local context, different policy instruments may be needed to specifically tackle the most pressing local issues. Recognizing differences in countries' contexts will help to develop realistic and applicable solutions.

Effectiveness of training and educational programs for hospital managers: A systematic review.

BACKGROUND: Developing and strengthening the competencies and skills of health care managers is a key objective in many health systems. Selecting adequate training methods, content, and using appropriate criteria for assessing their impact is fundamental for improving their usefulness and effectiveness. Filling an important gap in knowledge, this review assesses the evidence on the effectiveness of different types of training and educational programmes delivered to hospital managers. METHODS: In this narrative systematic review, the following electronic databases were searched for literature published between January 1st, 1990 and January 31st, 2019. The Joanna Briggs Institute (JBI) checklist was used to evaluate the quality of the included studies. RESULTS: In total, 9 articles were included. Results showed that the main topics covered by training programs for hospital managers were: planning, organization and coordination, control and supervision of hospital staff, teamwork, communication, motivation and leadership, monitoring and evaluation, and quality improvement skills. Training in these skills was found to improve managers' strategic and operational planning abilities, change management and behavioural management methods, and leadership. CONCLUSIONS: The examined training programs had a relatively positive effect on the managerial skills, knowledge and competencies of hospital managers. In general, these capacity-building programs focused on developing three types of skills: technical, interpersonal and conceptual. Training programs focused on developing technical skills among managers were more effective than those focused on developing other types of skills. Increased investment and large-scale planning are needed to develop better the knowledge and competencies of hospital managers.

Status, role, and performance of emergency medicine specialists in Iran: A qualitative study.

INTRODUCTION: The performance of the emergency department (ED) as one of the main parts of hospitals, have a great impact on the performance of the whole-hospital. In Iran, the official education program of this discipline was started in 2001 and has expanded in most medical universities. Given the unprecedentedness of emergency medicine (EM), there are limited studies about this specialty. Thus, this study aims to explore the status, role, and performance of Iranian EM specialists. MATERIALS AND METHODS: This qualitative study was conducted using content analysis of 19 semi-structured interviews with EM specialists and key informant. Purposive sampling was conducted, and some teaching and nonstate hospitals in different geographic regions of Tehran city were selected. Conducting interviews continued until reaching the data saturation. Thematic analysis was employed. Extracted themes were reviewed and confirmed by some of the participants. RESULTS: The study results were categorized within five main themes; included the role of ED from EM specialists' viewpoint, EM specialists' viewpoint on their discipline, performance of EM specialists (including medical, managerial, and economic performance), and role of EM specialists in patient satisfaction; and opportunities and challenges of EM specialists. CONCLUSION: Overall, the study findings highlighted the effectiveness and positive medical, managerial and economic impacts of EM in Iran, inside and beyond hospitals. However, the study addressed significant opportunities some solvable challenges in educational, professional and economic domains, and interdisciplinary relationships. Further studies are recommended for comprehensive exploring viewpoint of other disciplines and stakeholders.

Health Care Failure Mode and Effect Analysis in the Operating Room Setting.

OBJECTIVES: Operating rooms (ORs) and surgical settings are potential sources of sentinel adverse events. To better understand the characteristics of errors in OR processes, we performed prospective risk analysis. METHODS: The study was mixed qualitative and quantitative research. We used the Healthcare Failure Mode and Effect Analysis (HFMEA) method to analyze the selected perioperative, operative, and postoperative processes in the OR via a 2-round Delphi technique. We identified the most prominent failure modes according to a Hazard Decision Matrix, analyzed and categorized proposed possible causes, and provided solutions to mitigate hazard scores. RESULTS: Ten important processes and 7 subprocesses within the OR were selected and mapped, and 187 failure modes were identified and scored on the basis of severity and probability. A total of 36 potential failure modes were highlighted as high-risk failures and moved to decision trees for further analyses. CONCLUSION: Developing policy for the familiarization of new personnel designing a checklist for accurate gases counting; drafting comprehensive presurgical posters; preparing all necessary equipment in difficult intubation; developing instruction for monthly checking of the OR equipment; and developing the evaluation criteria of staff performance are examples of solutions that are proposed to improve the quality of OR processes.

Prevalence of self-medication in university students: systematic review and meta-analysis.

BACKGROUND: Self-medication can lead to serious consequences but its overall prevalence in students is not known. AIMS: The aim of this study was to determine the prevalence of self-medication in students through a systematic review and meta-analysis of studies on the prevalence of self-medication in students across the world. METHODS: PubMed/MEDLINE, EMBASE, ISI/Web of Science and Google Scholar were searched up to October 2017. Studies reporting the prevalence of self-treatment in university students were selected. Data recorded included year of publication, country where the study was conducted, sample size, prevalence of self-medication, sex and mean age of students, and faculty of students (medical or non-medical). A random-effect model was used to determine effect size with a 95% confidence interval (CI). Heterogeneity across studies was assessed with the I2 test. A sensitivity analysis assessed stability of the findings. RESULTS: A total of 89 studies were included in the analysis, which comprised 60 938 students. The overall prevalence of self-medication in university students was 70.1% (95% CI: 64.3-75.4%). Female students self-medicated more often than male students: odds ratio = 1.45 (95% CI%: 1.17-1.79). The prevalence of self-medication in medical students (97.2%) was higher than in non-medical students (44.7%). The I2 test indicated high, statistically significant heterogeneity. The sensitivity analysis showed that the results were stable. CONCLUSION: The prevalence of self-medication among students worldwide is high. Programmes on the risks of self-medication and increasing control and monitoring of the sale of drugs are recommended. Facilitating students' access to doctors and health centres could reduce self-medication in students.

Leveraging the COVID-19 response to improve emergency care systems in the Eastern Mediterranean Region.

The COVID-19 pandemic began as a cluster of reported cases of acute respiratory illness in China on 31 December 2019 and went on to spread with exponential growth across the globe. By the time it was characterized as a global pandemic on 11 March 2020, 17 of 22 countries in the Eastern Mediterranean Region (EMR) had reports of infected persons. EMR countries are particularly susceptible to such outbreaks due to the presence of globally interconnected markets; complex emergencies in more than half of the countries; religious mass gatherings that draw tens of millions of pilgrims annually; and variation in emergency care systems capacity and health systems performance within and between countries.