|Year : 2020 | Volume
| Issue : 3 | Page : 202-208
Patient safety in a Resource-constrained Context: A cross-sectional study of experience, drivers, barriers and preventive measures for safety incidents and accidents amongst medical doctors in South-east Nigeria
Gabriel Uche Iloh1, Ekene Agartha Emeka2, Augustine Obiora Ikwudinma3, Agwu Nkwa Amadi4
1 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State; Department of Medicine, College of Medicine and Health Sciences, Rhema University, Aba, Nigeria
2 Department of Family Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi; Department of Family Medicine, Nnamdi Azikiwe University, Awka, Nigeria
3 Department of Family Medicine, Alex Ekwueme Federal Teaching Hospital, Abakiliki; Department of Family Medicine, Alex Ekwueme University, Ndufu Alike, Ebonyi State, Nigeria
4 Department of Public Health, Federal University of Technology, Owerri, Nigeria
|Date of Submission||26-Feb-2020|
|Date of Decision||05-May-2020|
|Date of Acceptance||13-May-2020|
|Date of Web Publication||17-Jul-2020|
Prof. Gabriel Uche Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
Background: Globally, safety of patients in healthcare environment has been an issue of the decade, especially in resource-constrained settings. The Hippocratic maxim primum non nocere requires medical practitioners to give utmost importance to the principle of beneficence and safety in attending to patients. It is a current paradigm in quality of care metrics that determines what happens to patients who interface with the healthcare system. Aim: The study was aimed at describing the experience, drivers, barriers and preventive measures for patient safety incidents and accidents in a cross-section of medical practitioners in Abia State, Southeast Nigeria. Participants and Methods: This was a cross-sectional study carried out on 185 physicians in Southeast Nigeria. Data collection was done using a pre-tested, self-administered questionnaire that elicited information on experience, drivers, barriers and preventive measures for patient safety incidents. Results: The mean age ± standard deviation of the respondents was 36 ± 5.6 years, with a range of 25–72 years. There were 163 (88.1%) males and 22 (11.9%) females. Lifetime and previous 1-year committal of patient safety incidents were 100% (185/185) and 61.0% (113/185), respectively, with the most committed safety incident being medication errors. The most common driver of patient safety incidents was physician stress and burnout (100%) (185/185), whereas the most common barrier was communication (100%) (185/185). The most common preventive measure was patient safety incident reporting system (100%) (185/185). One-year committal of patient safety incidents was associated with duration of practice <10 years (P = 0.00001) and sex (P = 0.011). Conclusion: Patient safety incidents occurred amongst the study participants, with the most committed safety incident being medication errors. The most common driver was physician stress and burnout. The most common barrier was communication and feedback barrier, whereas the most common preventive measure was patient safety incident reporting system. Patient safety information, education and training should be the target for continuing professional development in order to safeguard the health of the patients in healthcare environment.
Keywords: Nigeria, patient safety, private and public medical practitioners
|How to cite this article:|
Iloh GU, Emeka EA, Ikwudinma AO, Amadi AN. Patient safety in a Resource-constrained Context: A cross-sectional study of experience, drivers, barriers and preventive measures for safety incidents and accidents amongst medical doctors in South-east Nigeria. Niger Postgrad Med J 2020;27:202-8
|How to cite this URL:|
Iloh GU, Emeka EA, Ikwudinma AO, Amadi AN. Patient safety in a Resource-constrained Context: A cross-sectional study of experience, drivers, barriers and preventive measures for safety incidents and accidents amongst medical doctors in South-east Nigeria. Niger Postgrad Med J [serial online] 2020 [cited 2020 Oct 28];27:202-8. Available from: https://www.npmj.org/text.asp?2020/27/3/202/289915
| Introduction|| |
Globally, safety of patients in healthcare environment has been an issue of the decade and is widely recognised as a pre-requisite for strengthening healthcare systems,,,, and achieving universal health coverage. In the old days of medicine, it was not well recognised that patients actually died from the care that they received rather than the disease and ailment for which they sought care in healthcare environment., In the now, a strong body of scientific literature reports the role of patient safety incidents and accidents in patient disability, disease, illness experience and death.,, Patient safety refers to safety in healthcare settings through prevention and reduction of risks, errors, harms and adverse events on patients during provision of healthcare. Patient safety incidents and accidents constitute one of the top 10 medical causes of disability worldwide and contributed to about 23 million disability-adjusted life years. In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care. In low- and middle-income countries (LMICs), each year 134 million adverse events occur in hospitals due to unsafe care resulting in 2.6 million deaths, and an estimated two-thirds of all adverse events resulting from unsafe healthcare, and the years of life lost to disability and death from inappropriate care occur in LMICs.
The magnitude of patient safety incidents and accidents has been reported amongst medical practitioners in the United States of America (USA), Italy, Belgium, India, Saudi Arabia, Sweden and elsewhere in sub-Saharan African countries such as Uganda, Ethiopia and Nigeria., Patient safety incidents and accidents have also been reported within and across different medical specialties and hospital settings of primary care practice, surgery,, obstetrics and gynaecology, operating rooms,, inhospital care, radiotherapy practice and outpatient care. The patient safety incidents and accidents can be caused by myriads of adverse events, with nearly 50% of them being preventable. However, the most detrimental unsafe care of great concerns is related to medication errors, diagnostic errors, healthcare-associated infections, unsafe surgical care, unsafe injection practices and radiation errors.
As a complex construct, patient safety is a multilayered phenomenon with ethical, moral, legal and sociocultural contexts and operations.,,, It is a cross- and interdisciplinary concept that cuts across various fields of medical, dental and surgical practice. Prescriptively, the Hippocratic maxim primum non nocere ( first, do no harm) requires medical practitioners to give utmost importance to the principle of beneficence and safety in attending to patients., The fundamental concepts and the principles of nonmaleficence (do no harm) in the codes of medical ethics remind medical practitioners to consider possible harms from medical interventions and act in the best interest of the patient to help prevent or remove harm., As the number of patients either injured, disabled or killed while accessing unsafe care has become an issue of global interest, invariably patient safety is a priority problem in healthcare with ongoing concerns around the world.,, In response to the emerging field of patient safety, international organisations such as the World Health Organization (WHO),, the Institute of Medicine (IOM) and the Joint Commission on International Accreditation (JCIA) have advanced evidence-based strategies that will result in elimination of patient safety incidents and accidents and for safer healthcare practices, climate and culture.
In order to raise awareness amongst health professionals, patients and responsible national and international governments and organisations, the 72nd World Health Assembly agreed that the World Patient Safety Day/International Day for Patient Safety (IDPS) be celebrated on 17 September every year., The new international day is part of the strategies to call the attention of policymakers across the globe to make healthcare safer and 17 September 2019 was the first edition and the theme was 'Patient safety: A global priority,' with the slogan for that day being 'Speak up for patient safety'. This demands medical practitioners to continuously incorporate elements of patient's safety into their patient care practice and also encourage other health professionals to contribute to the value chain of patient safety in healthcare environment. The creation of appropriate attitude towards patient safety incidents and accidents and overcoming the factors that predispose, prompt and perpetuate patient's safety concerns pre-eminently rely on practitioners of noble science and arts of medicine. This study was aimed at describing the experience, attitude, drivers, barriers and preventive measures for patient safety incidents and accidents in a cross-section of medical practitioners in Nigeria.
| Participants and Methods|| |
Ethical certification was obtained from the Health Research and Ethics Committee of Federal Medical Centre (FMC), Umuahia, with number FMC/QEH/G.596/Vol 10/294. Informed consent was also obtained from the respondents included in the study. This was a cross-sectional study of 185 private and public medical practitioners who participated in continuing professional development (CPD) programs organised by Directorate of Postgraduate Studies (DPGS) of FMC, Umuahia, on 3 and 4 May 2017, Nigerian Medical Association (NMA), Abia State, for 2017 Physicians Week and Annual General Meeting (AGM) of Association of Resident Doctors (ARD), FMC, Umuahia. The inclusion criteria were private and public medical practitioners who participated in CPD programs organised by DPGS, FMC, Umuahia, NMA Abia State Chapter or AGM of ARD, FMC, Umuahia. The questionnaire was administered to each eligible medical practitioner once either during CPD programs organised by DPGS, FMC, Umuahia, or NMA, Abia State, during the Physicians Week or AGM of ARD, FMC, Umuahia, respectively.
Sample size was determined using an online sample size calculating software. The input criteria for sample size estimation were set at 95% confidence level and accessible sample of 300 medical practitioners based on the previous CPD attendance registers of DPGS, FMC Umuahia and NMA, Abia State and AGM attendance register of ARD, FMC Umuahia. This gave a sample size estimate of 169 participants. The sample size calculating software assumed maximum possible proportion of 50% (0.50). To deal with incomplete response to the items on the questionnaire, the estimated sample size was increased by 5% incomplete response proportion, thus sample size = n/1 − incomplete response proportion at 5%. This gave a sample size of 178 respondents. However, sample size of 185 participants was used for the study. The eligible medical professionals for the study were consecutively recruited for the study based on the inclusion criteria until the sample size of 185 was achieved.
The study instrument consisted of sections on sociodemographic data such as age, sex and duration of practice. Experience, drivers, barriers and preventive measures for patient safety incidents and accidents were also studied. The experience, drivers, barriers and preventive measures for patient safety incidents and accidents sections of the study instrument were designed by the authors to suit Nigerian environment through robust review of appropriate literature on patient safety incidents and accidents.,,,,,,,,,,,,,,,,,,,,,, The face validity of the experience, drivers, barriers and preventive measures for patient safety incidents and accidents sections of the study instrument was evaluated by a panel of knowledgeable experts in occupational health, hospital ecology and public health who were not part of the study. The questionnaire was pre-tested using 10 medical practitioners from the General Outpatient Department of FMC, Umuahia. The pre-testing was done to ensure that the questions asked accurately reflected the information the researchers' desired and that the respondent interpreted and answered the questions correctly. However, no change was necessary after the pre-testing as the questions were interpreted with the same meaning as intended. Those used for the pre-testing of the study tool were excluded from the final study. The usability of the study instrument was assessed to determine the administration and interpretation by respondents and authors. The usability criteria for the use of a study tool where there is no existing pre-validated instrument were met. The questionnaire was self-administered since the participants are health literate.
Operationally, patient safety referred to the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare. These events include errors, mishaps, deviations and accidents. Patient safety incident referred to an event that under slightly different circumstances could have been an accident. This could be the result of a wrong or inappropriate action (error of commission) or failing to do the right thing (error of omission). Patient safety accident is an unplanned, unexpected and undesired event usually with an adverse consequence. Drivers of patient's safety incidents and accidents were factors that promote the likelihood of committal of patient safety incidents and accidents. One-year or life-time committal of patient safety incidents or accidents referred to committal of at least one patient safety incident or accident in the previous 1 year or lifetime as a medical practitioner, respectively.
The data generated were analysed using the Statistical Package for the Social Sciences (IBM SPSS) version 21, New York, USA. Frequencies and proportions were calculated for categorical variables, whereas mean and standard deviation were summarised for continuous variables. Chi-square test was used to test for significance of association between categorical variables. In all cases, P < 0.05 was considered statistically significant.
| Results|| |
Of the 185 medical doctors who participated in the study, 112 (60.5%) were young adults, 62 (33.5%) were middle-aged adults and 11 (6.0%) were older persons aged 60 years and more. The age of the participants ranged from 25 to 72 years, with a mean age of 36 ± 5.6 years. There were 163 males (88.1%) and 22 females (11.9%), with a male-female ratio of 7:1. One hundred and six (57.3%) participants had duration of practice of <10 years, whereas seventy-nine (42.7%) had years of practice of 10 years and more.
One hundred and eighty-five participants (100%) reported at least one lifetime committal of patient safety incidents, whereas 113 (61.0%) committed at least one patient safety incidents in the previous 1 year.
[Table 1] shows the types and drivers of patient safety incidents and accidents amongst the study participants. The most common patient safety incident was medication errors (100.0%), whereas the pre-eminent driver of patient safety incidents and accidents was work-related stress and burnout. The frequencies of other types and drivers of patient safety incidents and accidents are shown in [Table 1].
The most common barrier to patient safety incidents and accidents was communication and feedback errors (100%), whereas the predominant preventive measure was patient safety incident and accident documentation and reporting system (100%). The frequencies of other barriers and preventive measures are depicted in [Table 2].
|Table 2: Barriers and preventive measures for patient safety incidents and accidents (n=185)|
Click here to view
Chi-square analysis of the demographic characteristics of the study respondents as related to previous 1-year committal of safety incidents showed that duration of practice of <10 years (P = 0.00001) and male gender (P = 0.011) were statistically associated with previous 1-year committal of safety incidents [Tables 3].
|Table 3: Association between characteristics of participants and previous 1-year committal of safety incidents|
Click here to view
| Discussion|| |
This study has shown that all (100.0%) the participants reported at least one lifetime committal of patient safety incidents, whereas 1-year committal was 61.0%, with the most committed safety incident being medication errors. The finding of this study has demonstrated that medical practice in Nigeria is not an error-proof healthcare environment and is in consonance with reports from the USA, Italy, Belgium, India, Saudi Arabia, Sweden, Uganda and Ethiopia but varies in magnitude due to characteristics of the ecology of care in different parts of the world. According to these studies,,,,,,, and other reports,,, the most common patient's safety incident is caused by problems associated with inappropriate prescription of medications and results largely from inadequate knowledge of principles of pharmaceutical care and clinical inertia on the use of pharmacy and therapeutics safety nets amongst the prescribers.,,, Of great prominence in Nigeria is that inappropriate use of medications occurs with the prescriber, dispenser, administrator and the consumer, with each group contributing to the burden of medication errors., In addition, there are limited opportunities for medication reconciliations to prevent medication errors in public hospitals in Nigeria, and this is almost non-existent in most private clinics in the region. The finding of this study should stimulate the need for improved pharmaceutical care, responsible use of medications and appropriate use of credible sources of drug information with the view to promoting pharmaceutical safety. This, therefore, calls for interventional measures to increase and promote prescription safety with emphasis on effective collaboration between prescriber, dispenser, administrator and consumers of medicinal goods and products.
The most common driver of patient safety incidents and accidents was physician work-related stress and burnout syndrome. The finding of this study has lent credence to the reports that physician fatigue and burnout are risk factors for the occurrence of patient safety incidents and accidents., Admittedly, the tenets of medical ethics, and physicians' pledge advocate putting patients first and always. This is most likely to promote medical practitioner's burnout and affect personal, family and professional life. Dialectically, the medical doctor who committed therapeutic misadventure needs help too, and the health of medical practitioners was, therefore, the focus of the World Medical Association in 2017 with the recent modification of Physician Oath now called 'The Modern Physician Pledge' which states inter alia that 'I WILL ATTEND TO my own health, wellness and abilities in order to provide care of the highest standard'. Medical practitioners who care for themselves are more likely to provide safer care for patients and are less likely to commit patient safety incidents and accidents due to fatigue and burnout., There is, therefore, the need to mitigate the contagious effects of patient safety incidents and accidents on the second victim (medical doctor) with the aim of making the healthcare safer and less prone to errors to the first victim (the patient) and the effect on the second victim (the medical doctor).
The most common barrier to patient safety incidents and accidents was communication and feedback errors. Research studies have demonstrated the relevance of communication in patient safety incidents and accidents.,,, The finding of this study is in tandem with worldwide recognition that communication within and across professionals involved in patient care is essential in minimising patient safety incidents and accidents.,,, Overcoming communication barriers to patient safety involves incorporating information sharing, clear communication and collaboration every day and anytime patient encounters healthcare teams in order to safeguard the health of the patients, particularly in the environment where there are limited resources for standard patient care. This beckons for appropriate communication responses to unreasonable care causing patient safety misadventures through promotion of transparency in patient–hospital unsafe encounters and modification of practices to improve safety of patient care.,, Effective and effectual communications do not only minimise vicarious incident and accidents but also enhance efficacy and cost-effectiveness and promote intra- and interprofessional satisfaction and patient safety.
The most common preventive measure mentioned was patient safety incident reporting system. Undoubtedly, research reports from developed and developing countries have demonstrated that to achieve a complete medical error-free healthcare is a goal yet to be achieved by medical practitioners despite technological advances in patient care.,,,, Failure to acknowledge the occurrence of patient safety incidents and accidents in healthcare settings also increases the risk of medical misadventure. In response to the changing ecology of modern patients, the WHO,, IOM, JCIA and other researchers,,,,,,,,,, on patient safety studies have advanced effective and evidence-based interventions that will result in reduction of patient safety incidents and accidents. The theme for the maiden edition of 2019 IDPS was making patient safety a global priority, with the slogan for the year being speaking up for the patients., This theme and the slogan connote the centrality of patients in the healthcare setting and denote that what every patient experiences in healthcare environment affects utilisation and satisfaction with quality of care.,,, The practice of the science and arts of medicine should, therefore, be at the heart of every medical doctor in recognition of the principles of medical ethics which states inter alia 'Do no harm' (non-maleficence) and doing good (beneficence). The changing healthcare needs and demands for quality healthcare in Nigeria require that medical practitioners provide care that is aligned to global consensus on standard healthcare which is the pivotal function of responsive healthcare delivery system. Although patient safety incidents and accidents are our greatest teacher,, certain types of medical mishaps and misadventure are avoidable. Unavoidable patient safety incidents and accidents should be studied and openly discussed and must not be swept under the carpet. Medical practitioners should feel comfortable discussing and disclosing patient safety incidents and accidents including their own while maintaining a climate and culture of professional accountability, transparency and openness. Patient safety should be a habit not a choice anywhere, anytime and any day in healthcare environment.
Medical practitioners who were <10 years in medical practice committed more patient safety incidents and accidents in the previous 1 year when compared with those whose years of practice were 10 years and more. This could be a mirror of years of experience in medical practice amongst other characteristics of the study participants. Although committal of patient safety incidents in the previous 1 year was associated with duration of practice, no medical doctor comes to the hospital to render anything but an exemplary and high-quality care. With ongoing changing dynamics in patient care, improved patient health information, education and communication and easy availability of health information on the internet, the patient and public are prompted to seek assurances on the competence of medical practitioner and safety of medical practice irrespective of duration of practice of the attending physician.
The committal, drivers, barriers and preventive measures for patient safety incidents and accidents were based on respondents' subjective responses. However, there is a tendency to under-report episodes of patient safety incidents and accidents in addition to social desirable responses.
| Conclusion|| |
Patient safety incidents and accidents occurred amongst the study respondents, with the most committed safety incident being medication errors. The most common driver of patient safety incident and accident was work-related stress. The most common barrier was communication and feedback errors, whereas the most common preventive measure was patient safety incident reporting system.
Patient safety training, education and development should be the target of CPD amongst medical practitioners in order to safeguard the health of the patients in the healthcare environment. There is also the need for proactive interventional measures to reduce or minimise patient safety incidents and accidents such as the use of safety nets and other protocols, especially during prescription writing, while avoidable patient safety incidents and accidents should be disclosed, studied and openly discussed for incident and accident mitigation and risk reduction.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Jha AK, Larizgoitia I, Audera-Lopez C, Prasopa-Plaizier N, Waters H, Bates DW. The global burden of unsafe medical care: Analytic modelling of observational studies. BMJ Qual Saf 2013;22:809-15.
Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
Makary MA, Daniel M. Medical error the third leading cause of death in the US. BMJ 2016;353:I2139.
Brennan TA. The Institute of Medicine report on medical errors — Could it do harm? N
Engl J Med 2000;342:1123-5.
Smith CM. Origin and uses of primum non nocere—above all, do no harm! J Clin Pharmacol 2005;45:371-7.
Leape LL. Error in medicine. JAMA 1994;272:1851-7.
Iloh GUP, Chuku A, Amadi AN. Medical errors in Nigeria: A cross-sectional study of Medical Practitioners in Abia State. Arch Med Health Sci 2017;5:44-9. [Full text]
Wu AW, Boyle DJ, Wallace G, Mazor KM. Disclosure of adverse events in the United States and Canada: An update, and a proposed framework for improvement. J Public Health Res 2013;2:e32.
Flotta D, Rizza P, Bianco A, Pileggi C, Pavia M. Patient safety and medical errors: Knowledge, attitudes and behavior among Italian hospital physicians. Int J Qual Health Care 2012;24:258-65.
Vlayen A, Hellings L, Claes N. A nationwide hospital survey on patient safety culture in Belgian hospitals: Setting priorities at the lunch of a 5-year patient safety plan. Qual Saf Health Care 2012;21:760-7.
Patel S, Wu AW. Safety culture in Indian hospitals: A cultural adaptation of the safety attitudes questionnaire. J Patient Saf 2016;12:75-81.
Alahmadi HA. Assessment of patient safety culture in Saudi Arabian hospitals. Qual Saf Health Care 2010;19:e17.
Ridelberg M, Roback K, Nilsen P, Carlfjord S. Patient safety work in Sweden: Quantitative and qualitative analysis of annual patient safety reports. BMC Health Serv Res 2016;16:98.
Balidawa J. Patient safety culture of Iganga, Kamuli mission and Kakira hospitals of South Eastern Uganda. Texila Int J Public Health 2016;4:1-11.
Demisew A. Surgical site infection rate and risk factors among obstetrics cases of Jimma University Specialized Hospital, Southwest Ethiopia. Ethiopian J Health Sci 2011;21:91-100.
Chukwuneke FN. Medical incidents in developing countries: A few case studies from Nigeria. Niger J Clin Pract 2015;18 Suppl: S20-4.
Rees P, Edwards A, Panesar S, Powell C, Carter B, Williams H, et al
. Safety incidents in the primary care office setting. Pediatrics 2015;135:1027-35.
Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable? Arch Surg 2006;141:931-9.
Khan FA, Hoda MQ. A prospective survey of intra-operative critical incidents in a teaching hospital in a developing country. Anaesthesia 2001;56:177-82.
American College of Obstetricians and Gynecologists Committee Committee on Patient Safety and Quality Improvement. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol 2009;114:1424-7.
Gibbs VC. Patient safety practices in the operating room: Correct-site surgery and nothing left behind. Surg Clin North Am 2005;85:1307-19, xiii.
de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: A systematic review. Qual Saf Health Care 2008;17:216-23.
Boadu M, Rehani MM. Unintended exposure in radiotherapy: Identification of prominent causes. Radiother Oncol 2009;93:609-17.
Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: Estimations from three large observational studies involving US adult populations. BMJ Qual Saf 2014;23:727-31.
Glavin RJ. Drug errors: Consequences, mechanisms, and avoidance. Br J Anaesth 2010;105:76-82.
Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The landscape of inappropriate laboratory testing: A 15-year meta-analysis. PLoS One 2013;8:e78962.
Hutin YJ, Chen RT. Injection safety: A global challenge. Bull World Health Organ 1999;77:787-8.
Iloh GU, Onyemachi PE, Chukwuonye ME, Ifedigbo CV. Medical ethics in a resource-constrained setting: A cross-sectional study of awareness, attitude, practice, violations of its principles and ethical dilemmas experienced by medical professionals in Abia State, Nigeria. BLDE Univ J Health Sci 2018;3:89-96. [Full text]
IOM Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, DC: IOM Committee on Quality of Health Care in America; 2001.
Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, et al
. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood) 2011;30:581-9.
Iloh GU, Chukwuonye ME. Drug promotion in a resource-constrained Nigerian environment: A cross-sectional study of the influence of pharmaceutical sales representatives on the prescribing behaviours of Medical Practitioners in Abia State. Arch Med Health Sci 2017;5:215-22.
Salyers MP, Bonfils KA, Luther L, Firmin RL, White DA, Adams EL, et al
. The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. J Gen Intern Med 2017;32:475-82.
Dewa CS, Loong D, Bonato S, Trojanowski L. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: A systematic review. BMJ Open 2017;7:e015141.
Parsa-Parsi RW. The revised declaration of Geneva: A modern-day physician's pledge. JAMA 2017;318:1971-2.
Chesanow N. Does the Hippocratic Oath Promote Burnout? Medscape; 19 March, 2017.
Wu AW. Medical error: The second victim. The doctor who makes the mistake needs help too. BMJ 2000;320:726-7.
McDonald TB, Helmchen LA, Smith KM, Centomani N, Gunderson A, Mayer D, et al
. Responding to patient safety incidents: The “seven pillars”. Qual Saf Health Care 2010;19:e11.
Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med 2004;79:186-94.
Eisenberg EM, Murphy AG, Sutcliffe K. Communication in emergency medicine: Implications for patient safety. Commun Monographs 2005;72:390-413.
[Table 1], [Table 2], [Table 3]