Medical error reporting among doctors and nurses in a Nigerian hospital: A cross-sectional survey.

AIM: To compare doctors' and nurses' perceptions of factors influencing medical error reporting. BACKGROUND: In Nigeria, there is limited information on determinants of error reporting and systems. METHODS: From the total workforce (N = 600), 140 nurses and 90 doctors were selected by random sampling and completed the questionnaire February to March 2017. RESULTS: All 140 nurses and 90 doctors approached responded. Inter-professional differences in response to sentinel events showed that 55/140, 39.3% nurses and 48/90, 53.3% doctors would never report wrong medicines administered and 49/138, 35.5% nurses and 35/90, 38.9% doctors would never report a haemolytic transfusion error. Some respondents (72/140, 51.4% nurses vs. 29/90, 32.2% doctors) were unaware of reporting systems. Most (77/140, 55% nurses vs. 48/90, 53.3% doctors) considered these to be ineffective and confounded by a 'blame culture'. Perceived barriers included lack of confidentiality; facilitators included clear guidelines about protection from litigation. CONCLUSIONS: Error reporting is suboptimal. Nurses and doctors have a minimal common understanding of barriers to error reporting and demonstrate inconsistent practice. IMPLICATIONS FOR NURSING MANAGEMENT: Suboptimal reporting of serious adverse events has implications for patient safety. Managers need to prioritize education in adverse events, clarify reporting procedures and divest the organisation of a 'blame culture'.

Validation of a modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool: A mixed methods study.

AIMS AND OBJECTIVES: To develop and validate a modified Situation-Background-Assessment-Recommendation communication tool incorporating components of the Cape Town modified early warning score vital signs chart for reporting early signs of clinical deterioration. BACKGROUND: Reporting early signs of physiological and clinical deterioration could prevent "failure to rescue" or unexpected intensive care admission, cardiac arrest or death. A structured communication tool incorporating physiological and clinical parameters allows nurses to provide pertinent information about a deteriorating patient in a logical order. DESIGN: Mixed methods instrument development and validation. METHODS: We used a sequential three-phase method: cognitive interviews, content validation and inter-rater reliability testing to validate a self-designed communication tool. Participants were purposively selected expert nurses and doctors in government sector hospitals in Cape Town. RESULTS: Cognitive interviews with five experts prompted most changes to the communication tool: 15/42 (35.71%) items were modified. Content validation of a revised tool was high by a predetermined ≥70% of 18 experts: 4/49 (8.2%) items were modified. Inter-rater reliability testing by two nurses indicated substantial to full agreement (Cohen's kappa .61-1) on 37/45 (82%) items. The one item achieving slight agreement (Cohen's kappa .20) indicated a difference in clinical judgement. The high overall percentage agreement (82%) suggests that the modified items are sound. Overall, 45 items remained on the validated tool. CONCLUSION: The first modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool developed in South Africa was found to be valid and reliable in a local context. RELEVANCE TO CLINICAL PRACTICE: Nurses in South Africa can use the validated tool to provide doctors with pertinent information about a deteriorating patient in a logical order to prevent a serious adverse event. Our findings provide a reference for other African countries to develop and validate communication tools for reporting early signs of clinical deterioration.

Newly qualified South African nurses' lived experience of the transition from student to community service nurse: a phenomenological study.

BACKGROUND: This study attempted to fill a gap in the published South African literature regarding newly qualified nurses' preparedness for and experience of role transition to a 1-year compulsory commitment of community service nurse. METHODS: Husserlian descriptive phenomenology, characterized by inductive extraction of units of meaning from transcribed audiotaped recordings, was used to establish the "essence" of the lived experience of role transition. Data were collected from eight participants through two semistructured individual interviews: in July 2011, 2 weeks before the start of community service, and in September 2011, 6 weeks after community service placement. RESULTS: Findings showed that before placement, participants experienced a sense of achievement in having successfully completed a 4-year diploma program. However, they also experienced uncertainty and fear about the immediate future. In the first month after placement, community service nurses experienced reality shock. CONCLUSION: Preparation for the role transition from student nurse to graduate community service nurse requires a 4-year structured program that includes training in conflict management, assertiveness, and practical ethics.

Malawian mothers' experiences of raising children living with albinism: A qualitative descriptive study.

BACKGROUND: Albinism in humans is characterised by a reduced amount of pigment (melanin) present in the skin, hair follicles and the eye; approximately 7000-10 000 Malawians of all ages are affected. Children with these features face extreme forms of human rights abuses, even death. OBJECTIVES: This study aims to describe Malawian mothers' experiences, perceptions and understanding of raising children with albinism (CWA). METHODS: The study was conducted in 2018 using a qualitative descriptive design, with purposive sampling and voluntary participation. Mothers, 18 years and older, who had given birth to a CWA and who attended the dermatology clinic of a local public hospital participated. An interview guide used during standardised, open-ended interviews was translated from English to Chichewa using forward and backward translation. Interviews were conducted in Chichewa, audio recorded, transcribed and forward and back translated from English to Chichewa. Thematic data analysis was employed. RESULTS: The mean age of participants (N = 10) was 33 years; two had albinism. Emerging themes confirmed the existence of myths and stereotypes regarding albinism but from the mothers' perspectives. Mothers reported: (1) some experiences of emotional pain, initially, but also love and acceptance of their children, despite adverse reactions of others; (2) their experiences of stigmatisation of their children and themselves, and of intended harm to their children, and (3) their own lack of knowledge and understanding of albinism. CONCLUSION: In our limited study, mothers' self-reported experiences of raising CWA in Malawi highlight the need for educational programmes on albinism at national level, particularly for families with a CWA, health professionals and educators.

The influence of maternal blood glucose during pregnancy on weight outcomes at birth and preschool age in offspring exposed to hyperglycemia first detected during pregnancy, in a South African cohort.

INTRODUCTION: Little is known about the influence of hyperglycemia first detected in pregnancy (HFDP) on weight outcomes in exposed offspring in Africa. We investigated the influence of maternal blood glucose concentrations during pregnancy on offspring weight outcomes at birth and preschool age, in offspring exposed to HFDP, in South Africa. RESEARCH DESIGN AND METHODS: Women diagnosed with HFDP had data routinely collected during the pregnancy and at delivery, at a referral hospital, and the offspring followed up at preschool age. Maternal fasting, oral glucose tolerance test 1 and 2-hour blood glucose were measured at diagnosis of HFDP and 2-hour postprandial blood glucose during the third trimester. Offspring were classified as either those exposed to diabetes first recognized in pregnancy (DIP) or gestational diabetes (GDM). At birth, neonates were classified into macrosomia, low birth weight (LBW), large for gestational age (LGA), appropriate (AGA) and small for gestational age (SGA)groups. At preschool age, offspring had height and weight measured and Z-scores for weight, height and BMI calculated. RESULTS: Four hundred and forty-three neonates were included in the study at birth, with 165 exposed to DIP and 278 exposed to GDM. At birth, the prevalence of LGA, macrosomia and LBW were 29.6%, 12.2% and 7.5%, respectively, with a higher prevalence of LGA and macrosomia in neonates exposed to DIP. At pre-school age, the combined prevalence of overweight and obesity was 26.5%. Maternal third trimester 2-hour postprandial blood glucose was significantly associated with z-scores for weight at birth and preschool age, and both SGA and LGA at birth. CONCLUSION: In offspring exposed to HFDP, there is a high prevalence of LGA and macrosomia at birth, and overweight and obesity at preschool age, with higher prevalence in those exposed to DIP, compared to GDM. Maternal blood glucose control during the pregnancy influences offspring weight at birth and preschool age.

Testing effectiveness of the revised Cape Town modified early warning and SBAR systems: a pilot pragmatic parallel group randomised controlled trial.

BACKGROUND: Nurses' recognition of clinical deterioration is crucial for patient survival. Evidence for the effectiveness of modified early warning scores (MEWS) is derived from large observation studies in developed countries. METHODS: We tested the effectiveness of the paper-based Cape Town (CT) MEWS vital signs observation chart and situation-background-assessment-recommendation (SBAR) communication guide. Outcomes were: proportion of appropriate responses to deterioration, differences in recording of clinical parameters and serious adverse events (SAEs) in intervention and control trial arms. Public teaching hospitals for adult patients in Cape Town were randomised to implementation of the CT MEWS/SBAR guide or usual care (observation chart without track-and-trigger information) for 31 days on general medical and surgical wards. Nurses in intervention wards received training, as they had no prior knowledge of early warning systems. Identification and reporting of patient deterioration in intervention and control wards were compared. In the intervention arm, 24 day-shift and 23 night-shift nurses received training. Clinical records were reviewed retrospectively at trial end. Only records of patients who had given signed consent were reviewed. RESULTS: We recruited two of six CT general hospitals. We consented 363 patients and analysed 292 (80.4%) patient records (n = 150, 51.4% intervention, n = 142, 48.6% control arm). Assistance was summoned for fewer patients with abnormal vital signs in the intervention arm (2/45, 4.4% versus (vs) 11/81, 13.6%, OR 0.29 (0.06-1.39)), particularly low systolic blood pressure. There was a significant difference in recording between trial arms for parameters listed on the MEWS chart but omitted from the standard observations chart: oxygen saturation, level of consciousness, pallor/cyanosis, pain, sweating, wound oozing, pedal pulses, glucose concentration, haemoglobin concentration, and "looks unwell". SBAR was used twice. There was no statistically significant difference in SAEs (5/150, 3.3% vs 3/143, 2.1% P = 0.72, OR 1.61 (0.38-6.86)). CONCLUSIONS: The revised CT MEWS observations chart improved recording of certain parameters, but did not improve nurses' ability to identify early signs of clinical deterioration and to summon assistance. Recruitment of only two hospitals and exclusion of patients too ill to consent limits generalisation of results. Further work is needed on educational preparation for the CT MEWS/SBAR and its impact on nurses' reporting behaviour. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR201406000838118. Registered on 2 June 2014, www.pactr.org.

Renal unit practitioners' knowledge, attitudes and practice regarding the safety of unfractionated heparin for chronic haemodialysis.

BACKGROUND: Chronic haemodialysis for adult patients with end-stage kidney failure requires a patent extracorporeal circuit, maintained by anticoagulants such as unfractionated heparin (UFH). Incorrect administration of UFH has safety implications for patients. OBJECTIVES: Firstly, to describe renal practitioners' self-reported knowledge, attitudes and practice (KAP) regarding the safe use of UFH and its effects; secondly, to determine an association between KAP and selected independent variables. METHOD: A cross-sectional descriptive survey by self-administered questionnaire and non-probability convenience sampling was conducted in two tertiary hospital dialysis units and five private dialysis units in 2013. RESULTS: The mean age of 74/77 respondents (96.1%), was 41.1 years. Most (41/77, 53.2%) had 0-5 years of renal experience. The odds of enrolled nurses having poorer knowledge of UFH than registered nurses were 18.7 times higher at a 95% Confidence Interval (CI) (1.9-187.4) and statistically significant (P = 0.013). The odds of delivering poor practice having ≤ five years of experience and no in-service education were 4.6 times higher at a 95% CI (1.4-15.6), than for respondents who had ≥ six years of experience (P = 0.014) and 4.3 times higher (95% CI 1.1-16.5) than for respondents who received in-service education (P = 0.032), the difference reaching statistical significance in both cases. CONCLUSION: Results suggest that the category of the professional influences knowledge and, thus, safe use of UFH, and that there is a direct relationship between years of experience and quality of haemodialysis practice and between having in-service education and quality of practice.

Student nurses' recognition of early signs of abnormal vital sign recordings.

BACKGROUND: There is increasing urgency for nurses to recognize early signs of deterioration in patients and to take appropriate action to prevent serious adverse effects. OBJECTIVES: To assess respondents' ability to identify abnormal recordings for respiratory and heart rate, oxygen saturation level, systolic blood pressure, level of consciousness, urinary output and normal temperature. DESIGN: A descriptive observational survey. SETTING: A nursing college in Cape Town, South Africa. PARTICIPANTS: A sample of 77/212 (36.3%) fourth year students. METHODS: A self-administered adapted questionnaire was employed to collect demographic data and respondents' selections of recorded physiological values for the purpose of deciding when to call for more skilled help. RESULTS: The median age for 62/77 (80.5%) of the respondents was 25years; 3/76 (3.9%) had a previous certificate in nursing. Most respondents were female (66/76, 85.7%). Afrikaans was the first language preference of 33 (42.9%) respondents, followed by isiXhosa (31/77, 40.3%) and English (10/77, 13.0%). Most respondents (48/77, 62.3%) recognized a normal temperature reading (35-38.4°C). However, overall there would have been delays in calling for more skilled assistance in 288/416 (69.2%) instances of critical illness for a high-score MEWS of 3 and in 226/639 (35.4%) instances at a medium-score MEWS of 2 for physiological parameters. In 96/562 (17.1%) instances, respondents would have called for assistance for a low-score MEWS of 1. CONCLUSIONS: Non-recognition of deterioration in patients' clinical status and delayed intervention by nurses has implications for the development of serious adverse events. The MEWS is recommended as a track-and-trigger system for nursing curricula in South Africa and for implementation in practice.

Early warning scoring systems versus standard observations charts for wards in South Africa: a cluster randomized controlled trial.

BACKGROUND: On South African public hospital wards, observation charts do not incorporate early warning scoring (EWS) systems to inform nurses when to summon assistance. The aim of this trial was to test the impact of a new chart incorporating a modified EWS (MEWS) system and a linked training program on nurses' responses to clinical deterioration (primary outcome). Secondary outcomes were: numbers of patients with vital signs recordings in the first eight postoperative hours; number of times each vital sign was recorded; and nurses' knowledge. METHODS/DESIGN: A pragmatic, parallel-group, cluster randomized, controlled clinical trial of intervention versus standard care was conducted in three intervention and three control adult surgical wards in an 867-bed public hospital in Cape Town, between March and July 2010; thereafter the MEWS chart was withdrawn. A total of 50 out of 122 nurses in full-time employment participated. From 1,427 case notes, 114 were selected by randomization for assessment. The MEWS chart was implemented in intervention wards. Control wards delivered standard care, without training. Case notes were reviewed two weeks after the trial's completion. Knowledge was assessed in both trial arms by blinded independent marking of written tests before and after training of nurses in intervention wards. Analyses were undertaken with IBM SPSS software on an intention-to-treat basis. RESULTS: Patients in trial arms were similar. Introduction of the MEWS was not associated with statistically significant changes in responses to clinical deterioration (50 of 57 received no assistance versus 55 of 57, odds ratio (OR): 0.26, 95% confidence interval (CI): 0.05 to 1.31), despite improvement in nurses' knowledge in intervention wards. More patients in intervention than control wards had recordings of respiratory rate (27 of 57 versus 2 of 57, OR: 24.75, 95% CI: 5.5 to 111.3) and recordings of all seven parameters (5 of 57 versus 0 of 57 patients, risk estimate: 1.10, 95% CI: 1.01 to 1.2). CONCLUSIONS: A MEWS chart and training program enhanced recording of respiratory rate and of all parameters, and nurses' knowledge, but not nurses' responses to patients who triggered the MEWS reporting algorithm. TRIAL REGISTRATION: This trial was registered with the Pan African Clinical Trials Registry (identifier: PACTR201309000626545 ) on 9 September 2013.

Record review to explore the adequacy of post-operative vital signs monitoring using a local modified early warning score (mews) chart to evaluate outcomes.

OBJECTIVES: 1) To explore the adequacy of: vital signs' recordings (respiratory and heart rate, oxygen saturation, systolic blood pressure (BP), temperature, level of consciousness and urine output) in the first 8 post-operative hours; responses to clinical deterioration. 2) To identify factors associated with death on the ward between transfer from the theatre recovery suite and the seventh day after operation. DESIGN: Retrospective review of records of 11 patients who died plus four controls for each case. PARTICIPANTS: We reviewed clinical records of 55 patients who met inclusion criteria (general anaesthetic, age >13, complete records) from six surgical wards in a teaching hospital between 1 May and 31 July 2009. METHODS: In the absence of guidelines for routine post-operative vital signs' monitoring, nurses' standard practice graphical plots of recordings were recoded into MEWS formats (0 = normal, 1-3 upper or lower limit) and their responses to clinical deterioration were interpreted using MEWS reporting algorithms. RESULTS: No patients' records contained recordings for all seven parameters displayed on the MEWS. There was no evidence of response to: 22/36 (61.1%) abnormal vital signs for patients who died that would have triggered an escalated MEWS reporting algorithm; 81/87 (93.1%) for controls. Death was associated with age, ≥61 years (OR 14.2, 3.0-68.0); ≥2 pre-existing co-morbidities (OR 75.3, 3.7-1527.4); high/low systolic BP on admission (OR 7.2, 1.5-34.2); tachycardia (≥111-129 bpm) (OR 6.6, 1.4-30.0) and low systolic BP (≤81-100 mmHg), as defined by the MEWS (OR 8.0, 1.9-33.1). CONCLUSIONS: Guidelines for post-operative vital signs' monitoring and reporting need to be established. The MEWS provides a useful scoring system for interpreting clinical deterioration and guiding intervention. Exploration of the ability of the Cape Town MEWS chart plus reporting algorithm to expedite recognition of signs of clinical and physiological deterioration and securing more skilled assistance is essential.

Monitoring vital signs: development of a modified early warning scoring (MEWS) system for general wards in a developing country.

OBJECTIVE: The aim of the study was to develop and validate, by consensus, the construct and content of an observations chart for nurses incorporating a modified early warning scoring (MEWS) system for physiological parameters to be used for bedside monitoring on general wards in a public hospital in South Africa. METHODS: Delphi and modified face-to-face nominal group consensus methods were used to develop and validate a prototype observations chart that incorporated an existing UK MEWS. This informed the development of the Cape Town ward MEWS chart. PARTICIPANTS: One specialist anaesthesiologist, one emergency medicine specialist, two critical care nurses and eight senior ward nurses with expertise in bedside monitoring (N = 12) were purposively sampled for consensus development of the MEWS. One general surgeon declined and one neurosurgeon replaced the emergency medicine specialist in the final round. RESULTS: Five consensus rounds achieved ≥70% agreement for cut points in five of seven physiological parameters respiratory and heart rates, systolic BP, temperature and urine output. For conscious level and oxygen saturation a relaxed rule of <70% agreement was applied. A reporting algorithm was established and incorporated in the MEWS chart representing decision rules determining the degree of urgency. Parameters and cut points differed from those in MEWS used in developed countries. CONCLUSIONS: A MEWS for developing countries should record at least seven parameters. Experts from developing countries are best placed to stipulate cut points in physiological parameters. Further research is needed to explore the ability of the MEWS chart to identify physiological and clinical deterioration.

The biological sciences in nursing: a developing country perspective.

AIM: This paper reports a study to inform curriculum development by exploring the contribution of bioscience education programmes to nurses' clinical practice, their understanding of the rationale for practice, and their perceptions of their continuing professional development needs. BACKGROUND: The future of the health services worldwide depends on nurse education programmes equipping practitioners to deliver safe and effective patient care. In the developed world, the structure and indicative content of nursing curricula have been debated extensively. However, despite the rapid expansion in nursing roles brought about by social change, there is little information on the educational needs of nurses in developing countries. METHODS: This study was undertaken in government teaching hospitals in Cape Town, South Africa in 2003. A purposive sample of 54 nurses from a range of clinical settings completed questionnaires and described critical incidents where bioscience knowledge had directed practice. Questionnaires were analysed descriptively, in the main. Analysis of critical incident reports was based on Akinsanya's bionursing model. FINDINGS: Most nurses felt that their understanding of the biological, but not the physical sciences, was adequate or better: all felt confident with their knowledge of anatomy, compared with 57.4% (31/54) for microbiology. Respondents attributed the successes and failures of their education programmes to their teachers' delivery of content, ability to relate to practice and management of the process of learning. The biological, but not the physical, sciences were universally (96-100%) regarded as relevant to nursing. However, the critical incidents and nurses' own reports indicated a need for further education in pharmacology (40/54, 74.1%) and microbiology (29/54, 53.7%). CONCLUSION: To meet the needs of nurses in developing countries, and empower them to meet the increasingly complex demands of their expanding roles, nurse educators need to consider increasing the curriculum content in certain key areas, including pharmacology and microbiology.