# Patient Safety in Nigeria

Patient Safety in Nigeria is a field that is emerging because of the numerous harms to patients in healthcare practice. These harms are more pronounced in Nigeria because it is a developing country. Efforts need to be geared towards preventing, reducing and eliminating the harms.

## Brief overview of Nigeria

Nigeria has a land area of 923,770 km$^2$. It is the most populous nation in Africa with a population of over two hundred million citizens. Around half of Nigeria’s population is under 19 years old. The current life expectancy in Nigeria is 56.36 years.
Nigeria’s population is expected to be continuously increasing. One of the factors that have been responsible for the continued high population is the low crude death rate (15 per 1000 people in 1995, for instance) when compared with the crude birth rate (46 per 1000 in 1995, for instance). As a result, it was forecasted that there will be continued high population growth, which has always been the case in Nigeria. Orubuloye’s abstract on the demographic situation of Nigeria, in 1995, pinpointed some interwoven cause and effect factors namely, population growth, crude birth rate, crude death rate, political instability, economic difficulties, fertility rates, infant and child mortality, and government policy.

### Healthcare financing in Nigeria

Healthcare financing in Nigeria is inadequate and has an impact on patient safety in Nigeria. Healthcare financing is a mixture of government funding, personal charges, and private/insurance funding. Nigeria has a total of 39914 operational hospitals and clinics and 0.5 hospital beds per 1000 people. It has 0.381 and 1.7 units of doctors and nurses per 1000 people respectively.
The health sector funding of Nigeria is not meeting the African Union commitment of 15% of the total budget to the sector. Unavailability of fund and dwindling economy may have resulted in this. Also, the available scarce funds may not have been used judiciously. The continuous drastic increase in the population of Nigeria, due to a high fertility rate of 4.92 births per woman is adversely affecting the economic and health status of the country also. This is more so due to the triangular dynamic equilibrium between the trios of population, economic and health status. Inadvertently, the continuous increase in population has had an economic impact on, and has led to, inadequate financing of the healthcare sector. A typical example is the stopped free healthcare program of the Osun State government, one of the 36 states in Nigeria, as a result of an economic crisis in 2015. This led to the creation of Public Private Partnership in the hospital pharmacies of the State.
The Nigeria National Health Insurance Scheme (NHIS) is an approach that the Nigerian government has adopted to ensure that citizens have access to quality health care while ensuring financial risk protection. The NHIS aims to provide an avenue for the achievement of Universal Health Coverage (UHC). There have been success stories recorded though, failings are not left out. One of the shortcomings is that the scheme does not cover some procedures or drugs.

## Patient harm in Nigeria healthcare system

The most common forms of harm in Nigeria’s healthcare system are harm due to overtreatment and harm due to failure to provide appropriate treatment. Polypharmacy typically represents the harm due to overtreatment. It is not uncommon to see prescriptions containing several medications, five or more. The Beers Criteria and World Health Organization’s report on medication safety in polypharmacy is useful in informing the decision of harm due to overtreatment. The Beers Criteria, as a tool, listed potentially harmful drugs (especially in the elderly). Criteria in the Beers Criteria tool has been found wanting in Nigerian healthcare settings. One of the research projects conducted with the tool in Nigeria is the Akande-Sholabi et al. paper which clearly showed that the prevalence of polypharmacy among geriatric patients is almost one in every four patients (23.8%) and the average medications prescribed was found to be 4.
Harm due to failure to provide appropriate treatment, which is a form of medical negligence, can be seen. Though no institutional protocol is available for detecting harm due to failure to provide appropriate treatment in the healthcare setting in Nigeria, discourses, searches and research have shown it is common. A typical example, from experience, is the prescribing of non-steroidal anti-inflammatory drug (NSAID) to a patient with a medical history of peptic ulcer as a result of failure to seek medical history.
Language and culture can also serve as one of the factors responsible for patient harm in Nigeria. It serves as a barrier to accessing health information and ensuring patient safety in some situations. Nigeria is diverse and made up of 371 tribes. A healthcare professional from a particular region that has to be newly introduced and work in another region may face a daunting task in communication with patients. This may harm patient safety. Most times, interpreters are relied on. However, this may be time-consuming and the information may not be perfectly relayed as expected by the healthcare professionals sometimes.
Lengthy patient waiting time is another factor responsible for patient harm in healthcare settings in Nigeria, especially when the waiting periods are undue delay. For instance, a published work on waiting time in the pharmacy department of a tertiary hospital reveals a long delay in care is being experienced by patients. Patients were not satisfied with the undue delay. This is one of the systemic factors that may lead to patient harm due to fatigue experienced by patients while waiting. Suggestion was made that more time should be spent on pharmaceutical counseling and less time on the dispensing process.

## Effect of non-technical skills on patient safety in Nigeria

Non-technical skills are a set of skills of an individual or a team that support learned technical skills. They include cognitive biases, communication and team dynamics. They have had effect on patient safety in the Nigeria healthcare system. As examples, areas where technical skills have had effect on pharmacy practice are explained below.

### Cognitive biases

Cognitive biases have contributed to errors and adverse events in several areas of pharmacy practice. These include decisions in the making of drug formulary, pharmaceutical development, pharmaceutical marketing/sales, conversations with patients, and pharmaceutical counselling, among others.

### Communication

Communication breakdown has threatened patient safety and harmed patients while discharging pharmaceutical services. It has led to medication errors while filling prescriptions, errors while counseling patients on medication use, a threat to patient safety as a result of unresolved disagreement during communication, and harm due to failure to communicate appropriately with patients on safety concerns (side-effects) of drugs, among others.

### Team dynamics

Team dynamics do have impacts on patient safety. For instance, the interprofessional rivalry in the Nigeria healthcare sector has led to strikes in healthcare institutions which left patients in danger. Stress of healthcare professionals have contributed to the degradation of healthcare team performance also. Various sources of stress that have been identified include heavy workload, incivility, dissatisfaction with working conditions, bad leadership and, little reward for work done, among others.

## Human factors in Nigeria's healthcare system

Human factors is a discipline that takes into account the abilities and limitations of people in the execution of tasks or completion of assigned work. It recognizes that humans make errors and consider for designing a safe workplace. The discipline is rare to come across in Nigeria's healthcare system and should be implemented. Human factors help see a better way of ensuring safety and quality improvement, in healthcare system and, of patient care. Its focus on fitting the work to the workers rather than fitting the workers to the work is perfectly in order. Fitting the work to the worker is an ideal way of putting the round peg (the right work) in the round hole (to the corresponding abilities of the worker).
Human factor discipline helps create a better design of a system for quality improvement. In a healthcare system, this will improve the quality of care to patients and enhance patient safety. By such designs, the healthcare system will be better equipped to prepare for any unwanted scenario of preventable and/or unnecessary harms to patients and/or the healthcare force.
Human factors/ergonomics (safety science) helps to see quality improvement of health and social care is better achieved by focusing on fitting the work to workers rather than the workers to the work. Getting to know the specific characteristics of each worker, as each worker has different strength and thinking ability, has been recognized as the best way to go in harnessing their potential to the fullness. In addition, the knowledge of the interaction between people and equipment, work environments, and work activities is important for patient safety and quality improvement. This in turn will lead to optimizing human well-being and the healthcare system performance.

## The Society for Quality in Healthcare in Nigeria

The Society for Quality in Healthcare in Nigeria (SQHN) is advocating for patient safety in Nigeria. The society publishes a newsletter to ensure awareness of the need for patient safety. It also conducts training occasionally. It makes provision for registering members to ensure the widespread of its vision. Hospitals are also encouraged to sign up for accreditation in the society.

## Recommended strategies to improve the safety of healthcare in Nigeria

Strategies that have been recommended to be useful for improving patient safety include leadership and enhancing knowledge, identifying and learning from errors, setting standards and expectations for safety, and implementing safe systems within healthcare organisations. An example of demonstrating leadership and enhancing knowledge is leaders in healthcare organizations creating awareness and education/training programs on patient safety and its relevance in healthcare settings. The awareness of patient safety in Nigeria is currently low.
A typical example of identifying and learning from error is having a pharmacovigilance form where all adverse drug reactions are reported and collated. Adverse drug reactions are the unwanted and unexpected consequences from the use of medications. The pharmacovigilance form is already in existence in Nigeria but its implementation and monitoring could be improved. From the data gathered from the form, measures can be taken to prevent the future occurrence of these unwanted consequences.
Setting standards and expectations for safety is important to ensure that healthcare provision meets the requirements of safety and quality. Standards can be set at the local level or national level. Organizations, associations, and/or professional groups can set standards also. It has been revealed that standards could manage hazardous technologies if three criteria are met:
* Setting general standards is preferable to case-by-case decision-making;
* Some general safety philosophy, balancing risk and other factors, can be justified on normative grounds and;
* Philosophy is faithfully translated into operational terms. An example of such is the standard treatment guidelines for malaria which incorporate Artemisinin Combination Therapy (ACT) as the first line of therapy for treating malaria and exclude Chloroquine (for safety and quality care issues). In the guideline, some antimalarial drugs were excluded in pregnant women. Sulphadoxine-Pyrimethamine was advised to be used as a prophylactic antimalarial in pregnant women, especially in a malaria-endemic area like Africa.
Implementing safe systems, by erasing unsafe acts in healthcare organizations within healthcare organizations, has been recommended. It can ensure a safety culture in the healthcare environment where all employees are safety conscious and will imbibe it as a way of life for good practice. This can ensure both the healthcare professionals and patients are in a safe environment. Design of the healthcare system with the aid of human factors to ensure safety can also help. Human factors/ergonomics (safety science) helps to see quality improvement of health and social care can be better achieved through focusing on fitting the work to workers rather than the workers to the work. Getting to know the specific characteristics of each worker, as each worker has different strengths and thinking abilities, can be used to harness workers' potential to the fullest. In addition, the knowledge of interaction between people and equipment, work environments, and work activities is important for patient safety and quality improvement. This, in turn, can lead to optimizing human well-being and the healthcare system's performance. Gaining knowledge of this concept can improve patient safety and quality improvement in Nigeria.