|Year : 2017 | Volume
| Issue : 1 | Page : 44-49
Medical errors in Nigeria: A cross-sectional study of medical practitioners in Abia State
Gabriel Uche Pascal Iloh1, Abali Chuku2, Agwu Nkwa Amadi3
1 Department of Family Medicine; Ophthalmology, Federal Medical Centre, Umuahia, Abia State, Nigeria
2 Department of Ophthalmology, Federal Medical Centre, Umuahia, Abia State, Nigeria
3 Department of Public Health, Federal University of Technology, Owerri, Imo State, Nigeria
|Date of Web Publication||16-Jun-2017|
Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
Background: Human errors in health-care delivery have always been a challenge since the Hippocratic dictum “First, do no harm.” However, to achieve a complete error-free health care is a goal yet to be achieved by health professionals despite technological advances in patient care. Aim: The study was aimed at describing medical errors in a cross-section of medical practitioners in Abia State, Nigeria. Materials and Methods: A descriptive study was carried out on a cross-section of 145 medical practitioners in Abia State, Nigeria. Data collection was done using pretested, self-administered questionnaire that elicit information on types, committal, disclosure, and attitude to medical errors. Lawsuits and psychological disturbances associated with committal of medical errors were also studied. Results: The prevalence of medical errors was 42.8%. The three most common errors committed by the participants were an error of medication prescription (95.2%), error of radio-laboratory investigation ordering (83.9%), and error of physician diagnoses (69.4%). Sixty-two (100%) of the participants who committed medical errors had a negative attitude to error disclosure to the patients and their families. Of the 62 participants who committed medical errors, 33.8% were depressed. Among those that committed medical errors, none was involved in a lawsuit for medical errors. Committal of medical errors was associated with years of practice <10 years (P = 0.011). Conclusion: Medical errors occurred among the study participants with the most common error committed being prescription errors. The attitude to error disclosure to the patient was negative. There is a need for the use of safety net and other protocols especially during prescription while avoidable errors should be disclosed, studied, and openly discussed for error mitigation.
Keywords: Abia State, medical errors, Nigeria, private and public medical practitioners
|How to cite this article:|
Iloh GU, 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
|How to cite this URL:|
Iloh GU, Chuku A, Amadi AN. Medical errors in Nigeria: A cross-sectional study of medical practitioners in Abia State. Arch Med Health Sci [serial online] 2017 [cited 2022 Sep 25];5:44-9. Available from: https://www.amhsjournal.org/text.asp?2017/5/1/44/208180
| Introduction|| |
Human errors in health-care delivery have always been a challenge since the Hippocratic dictum “ first, do no harm.” Medical errors are human errors in the process of care delivery and is a significant cause of morbidity and mortality among patients with grave consequences for family and public health.,, In the old days of medicine, it was not well recognized that patients actually die from the care that they receive rather than the disease for which they seek care. In the now, a strong body of scientific literature reports the role of medical errors in patient death ,, and is one of the top 10 medical causes of disability worldwide constituting about 23 million disability-adjusted life years.
Globally, it is estimated that 142,000 people died in 2014 from medical errors which was an increase from 94,000 people in 1990. However, reports from 2016 annual deaths of 251,454 from medical errors in the United States of America suggested that 2013 global estimation may not be accurate. In the year 1999, the Institute of Medicine Committee on the quality of health care in America brought to the medical and public attention the issues of medical errors and highlighted the gross under-reporting of medical errors and that the estimates of undisclosed medical errors could be in millions. In the past, medical practitioners are far less likely to be sued for medical errors than they are in the present and it is a common fear in the now that medical error disclosure to the patient and family would incite a lawsuit., However, research studies have shown that the patients and families that considered litigation for medical errors are likely those who were more dissatisfied with the explanation they received from the medical practitioner., Admittedly, medical errors do not necessarily constitute unethical behavior but failure to disclose error may. While patients and the public support disclosure of medical errors, physicians also indicated support for error disclosure but often do not disclose errors., Professional and ethical guidelines, and patient safety organizations , recommends disclosure of medical errors and the recent quality of care in health-care settings link disclosure of unexpected outcomes to hospital accreditation.
In general, medical error refers to any type of error, event, mistake, mishap, incident, accident, or deviation from process of care regardless of whether or not it results in patient harm or death., The causes and risk factors of medical errors could be health professional-, patient-, and system-related.,, The vast majority of medical errors result from human and system errors especially poorly designed and articulated process of care and incompetent medical practitioners. Although other healthcare professionals commit health-care errors research studies have indicated a geometric rise in the frequencies of medical errors with overwhelming majority of this increase being physician-related.,, There is plethora of research studies on medical errors in advanced nations with variable dimensions of medical errors including error of diagnoses, medication errors, diagnostic errors, therapeutic errors, surgical errors, procedural errors, facility accidents, error of uncoordinated care, never happen events, hospital acquired infections, missed warning signs, referral errors, and untimely discharged from health facility among others.,,,,,,,,,
The biomedical literature, particularly from advanced nations, has demonstrated that health-care system is failing in the management of its errors and this causes hazards that often harm and sometimes kill rather than help the patients resulting in malpractice risks and claims.,,,, In 2010, a survey of physicians in the United States of America, 42.2% of the practitioners were involved in at least one medical litigation  while in 2015, a survey of primary care physicians and some selected specialists 59% of the respondents were involved in at least one malpractice suit. The uncertainty regarding legal modifications in medical errors restricts rather than enlighten medical practitioners so that medical professionals practice defensive rather than legally protected medicine.,, However, concerns regarding legal liability which might result from truthful disclosure should not affect the physician honesty with the patients, and the medical doctor is ethically require to inform the patient of all facts necessary to ensure understanding of medical errors. Medical errors have been reported to have patient- and physician-related consequences in the ecology of medical care: To the first victim (the patient) it could lead to no harm with emotional upheavals, harm and death ,, while to the second victim (the medical doctor) it affects physician-patient relationships, public image of the physician and other negative consequences such as medical litigations and claims, physician depression and suicide.,,,,
The magnitude of medical errors has been reported to vary by medical specialties , and by geographic expression within and across the global population ,,,, in the United States of America,,, the United Kingdom, Italy, and Australia. In Nigeria Africa, medical errors have not been quantified, and there is poverty of research on medical errors. However, anecdotal and current information suggest that medical errors are more than expected in the subregion. Of great interest in Nigeria is that reporting of medical errors and learning from adverse events and near misses in health facility settings are important healthcare challenge that are often neglected. The identification of common errors particularly those that are physician-related which are amenable to effective interventions avails the great opportunity for error reduction. It is based on this background that the researchers were motivated to describe medical errors in a cross-section of medical practitioners in Abia State, Southeast Nigeria.
| Materials and Methods|| |
This was a descriptive cross-section carried out between July 6, 2016, and July 7, 2016, on 145 private and public medical practitioners who participated in a continuing professional development program organized by Directorate of Postgraduate Studies of Federal Medical Centre Umuahia for medical practitioners in Abia State, Nigeria. Federal Medical Centre, Umuahia is a licensed continuing professional development provider in Nigeria.
The inclusion criteria were private and public medical practitioners in Abia State who registered and participated in the continuing professional development program. Exclusion criteria were postgraduate resident medical doctors and house physicians who do not require continuing professional development points for annual renewal of their licenses by the Medical and Dental Council of Nigeria.
Sample size estimation was determined using the formula for estimating minimum sample size for descriptive studies  using the formula n = Z2pq/d2 and nf = n/1 + n/N where n = Desired sample size when population is > 10,000; nf = Desired sample size when population is < 10,000; Z = Standard normal deviate set at 1.96 which corresponds to 95% confidence limit; P = Since there is no similar research on medical errors in Nigeria, authors assumed that 50% (0.50) of the participants would have committed medical error; d = Desired level of precision set at 0.05. When studying population < 10,000 using an estimated population size of 200 medical practitioners based on the previous medical practitioners continuing professional development attendance records at the Directorate of Postgraduate Studies, Federal Medical Centre, Umuahia. These 200 medical practitioners excluded resident doctors and house officers. This gave a sample estimate of 132 patients. However, sample of 145 medical practitioners was used to improve the precision of the study.
The eligible medical practitioners for the study were consecutively recruited for the study based on the inclusion criteria until the sample size of 145 was achieved.
The study instrument consisted of sections on sociodemographic data, information on types of medical errors, committal, disclosure, and attitude to medical errors. Lawsuits and psychological disturbances associated with committal of medical errors.
The questionnaire was designed by the authors through robust review of literature on previous studies on medical errors.,,,,,,,,,,, The questionnaire consisted of dichotomous, matrix and open-ended questions which were structured in such a way that could elicit immediate answers from the respondents. The questionnaire was pretested using 10 postgraduate resident medical doctors in Federal Medical Centre, Umuahia. The pretesting was done to find out how the questions would interact with the respondents and ensure there were no ambiguities. However, no change was necessary after the pretesting as the questions were interpreted with the same meaning as intended. The questionnaire was self-administered since respondents are health literate.
The data generated were analyzed using software Statistical Package for Social Sciences version 21 (IBM SPSS, New York, USA). Categorical variables were described by frequencies and percentages. Bivariate analysis involving Chi-square test was used to test for significance of the association between categorical variables. The level of statistical significance was set at P < 0.05.
| Results|| |
Of the 145 respondents who participated in the study, 109 (75.2%) were middle-aged adults (40–59 years), 34 (23.5%) were young adults (18–39 years), and 2 (1.3%) were aged 60 years and more. There were 136 males (93.8%) with 9 females (6.2%) [Table 1].
Of the 145 respondents who participated in the study, 62 of them had committed at least one medical error giving a prevalence of 42.8% with the most common error committed being an error of medication prescription (95.2%). Others included error of radio-laboratory investigation ordering (83.9%), error of physician's diagnoses (69.4%), surgical errors (29.0%), and procedural errors (25.8%) [Table 2] and [Table 3].
Of the 62 participants who committed medical, the attitude of 62 (100%) who committed medical error to error disclosure to the patients and families was negative. On psychological disturbance as a consequence of committal of medical errors, 28 (45.2%) of the participants had no psychological disturbance; 21 (33.8%) had depression; and 13 (21.0%) had acute anxiety disorder while Of the 62 participants who committed medical errors, none of them was involved in a lawsuit for medical errors [Table 4].
|Table 4: Attitude to disclosure of medical errors to the patients, types of psychological disturbance and lawsuits for medical errors among the participants who committed medical errors (n=62)|
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On bivariate analysis of the association between committal of medical errors and sociodemographic characteristics of the study participants, respondents who had years of practice <10 years committed more medical errors than those with years of practice 10 years and more. This finding was statistically significant (P = 0.011). Participants with years of practice <10 years were twice more likely to commit medical errors compared to their counterparts with years of practice 10 years and more [Table 5].
|Table 5: Association between age, sex, years of medical practice, and committal of medical errors|
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| Discussion|| |
This study has shown that 42.8% of the participants had committed at least one medical error in the process of patient care. The findings of the study have shown that medical practice in Nigeria Abia is not an error-proof environment of care and is in tandem to what is reported in other parts of the world such as the United States of America,,,, the United Kingdom, and Italy, but varies in magnitude and epidemiological characteristics of the study population. The magnitude of medical errors in this report is likely a tip of an iceberg in the study area where surgical procedures take place in under-equipped operating theaters checklists are missing or remain uncompleted, clinical inertia on the use of practice guidelines, poor knowledge of pharmaceutical care and defective laboratory results and reports. According to the research reports from developed countries ,,,, to achieve a complete error-free health care is a goal yet to be achieved by health-care practitioners despite technological advances in patient care. Failure to acknowledge the occurrence of medical errors in health-care settings also increases the risk of medical errors. In response to the evolving burden of medical errors, International Society for Quality in Healthcare  and researchers on the quality of care ,, have advanced effective and evidence-based interventions that will result in a reduction of medical errors. Concerns regarding medical errors if not properly managed may have far reaching consequences on medical practice in the subregion. This study, therefore, informs the need to appraise the structure and process of our service delivery to the consumers of health-care goods and services. This will enable medical practitioners to avert medical errors that ordinarily would have led to litigation. Regular study of risk factors of medical errors in Nigeria will provide insight into the current trend and will help strengthen effective interventional measures.
The most common error committed by the participants was an error of medication prescription. This is in consonance to the most common errors reported in other parts of the world with medication errors being the most hot-button medical errors.,,,,,, Interestingly, pharmaceutical care is still a Gordian knot to untie particularly in Nigeria where inappropriate use of medication occurs with the prescriber, the dispenser, and the consumer., Of great concern in Nigeria is that opportunities for medication reconciliation to prevent medication errors are very few in public hospitals and almost nonexistent in most private clinics. This could be attributed to physician-patient or pharmacist-patient contact times which are very short in public hospitals and even sometimes almost unavailable in most private hospitals in Nigeria. The finding of this study, therefore, stimulates the need for improved pharmaceutical care as well as responsible use of medications , with the view to promoting patient safety in Nigeria. This study draws the attention of medical practitioners on the relevance of assuring patient safety and also reduces the chances of medication-related problems to improve pharmaceutical outcomes. There is need more than ever before for continuing professional development on principles and practice of therapeutics for all medical practitioners in Nigeria in addition to training and encouraging them to use credible sources of drug information.
This study has shown that none of the medical errors were disclosed to the patient or their families or reported appropriately and the attitude to error disclosure to the patient was negative. This finding is in contrast to what is obtained in advanced countries ,,,, where error disclosures to patients or reporting of medical errors to appropriate hospital authorities have been described. Apart from true incompetence, ideally no medical doctor comes to the hospital expecting to render anything but exemplary care and disclosure of medical error is not to shame or blame the medical practitioner or the health facility.,, Ironically, one preventive strategies to decrease the number of error induced patients injuries and fatalities is disclosure of medical errors. Although there are significant gaps in the conceptualization and operationalization of medical error disclosure between the field of medical ethics and law medical practitioners should feel responsible toward their patients and medical profession to disclose any medical error arising from the patient care.,, There should, therefore, be a responsible way to tell the truth at no risk to the physician while some degree of formal control over litigation for medical errors., Disclosure of medical errors helps both in drawing attention to the issues that surround the error and provides a wealth of knowledge. However, such information from physician apology for medical errors should not be used in malpractice courts even a full admission of fault.
Of the 62 participants who committed medical errors, none was involved in a lawsuit for medical errors. This finding is in contrast to what is obtained in advanced countries where malpractice suits for medical errors have been reported.,, However, research studies have shown that majority of medical errors are unreported and medical practitioners breach the standard of professional and ethical practice.,,,, In Nigeria Africa, the paucity of litigation on medical errors is due to factors such as religious beliefs, cultural disposition, cost and time spent on lawsuits, ignorance and other diverse factors. With ongoing dynamics in patient care and improvement in patient information, education, and communication, the patient and public seek assurances on the competence of medical professionals and safety of medical practice. This study, therefore, should arouse the consciousness of medical professionals in Nigeria concerning the reality of medical errors and its attendant litigation, particularly in a resource-poor Nigerian environment.
Of the 62 participants who committed medical errors, 33.8% were depressed. This is in agreement with research studies on medical errors with depression being the most common psychological disturbance associated with medical errors.,, According to these reports, the medical practitioner who committed medical errors needs help too., Forgiveness which is part of many cultural traditions may be important in coping with medical errors. With honesty and transparency, healing can begin not just for the patients and their families but also the second victim (the medical doctor) who committed the medical errors., There is, therefore, the need to mitigate the contagious effects of medical errors on the second victim with the aim of making the healthcare safer and less threatening to the first victim (the patient) and the second victim (the medical doctor).
On bivariate analysis, respondents who were <10 years in medical practice committed more medical errors when compared with those whose years of practice were >10 years. This could be a mirror of years of experience in medical practice among other epidemiological variables.,, Admittedly, there is no perfect health system within which humans will no longer commit errors in the process of health delivery. Medical practitioners irrespective of their years of practice are proponents of the Hippocratic dictum that guides medical practice and obligates the medical practitioner to “ first do no harm.”, The current standard of practice at many hospitals is to disclose medical errors to patients and their families when they occur. This encourages medical practitioner to acknowledge and explain mistakes to the patients keeping an open line of communication. However, due to broader nature of medical errors,, emphasis should be on human performance in addition to health system responsiveness and rethinking.
Implications of the study
The findings of this study have significant implications for medical practitioners involved in patient care. It illustrates that medical errors occur in Nigeria health-care delivery system and this should be taken into consideration during programs on continuing professional development and quality improvement in health-care facilities. Health-care professionals responsible for patient care in the subregion need to develop a robust system of reporting of medical errors and giving the information appropriately. Ethical and professional guidelines recommend disclosure of medical errors to the patients and families. When medical errors occur, effective physician-patient/family communication is critical in its management.
Limitations of the study
The limitations of this study are recognized by the researchers. First and foremost, the study was carried out in Abia State, and the findings may not be generalized to other parts of Nigeria. Second, the occurrence and disclosure of medical errors were based on respondents' subjective experience and were not verified. However, there is a tendency to under-report episodes of medical errors in addition to social desirable responses. Finally, the details of specialties of the participants and specific medical errors were not considered and these important areas of medical errors require further study.
| Conclusion|| |
This study has demonstrated that medical errors occurred among the study participants with the most common error committed being medication prescription errors. The attitude to error disclosure to the patient and families was negative. The most common psychological disturbance associated with the committal of medical error was depression. None of the medical practitioners who committed medical errors was involved in a lawsuit and committal of medical errors was associated with less than 10 years of practice.
There is a need for proactive interventions to minimize medical errors such as the use of safety net and other protocols especially during prescription while avoidable errors should be disclosed, studied, and openly discussed for error mitigation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Smith CM. Origin and uses of primum non nocere – Above all, do no harm! J Clin Pharmacol 2005;45:371-7.
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.
Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016;353:i2139.
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.
GBD Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385:117-71.
Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
Hingorani M, Wong T, Vafidis G. Patients' and doctors' attitudes to amount of information given after unintended injury during treatment: Cross sectional, questionnaire survey. BMJ 1999;318:640-1.
Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994;343:1609-13.
Sweet MP, Bernat JL. A study of the ethical duty of physicians to disclose errors. J Clin Ethics 1997;8:341-8.
Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: A review of the literature. Arch Intern Med 2004;164:1690-7.
Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, et al.
Views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:1933-40.
Leape LL. Error in medicine. JAMA 1994;272:1851-68.
Joint Commission on Accreditation of Healthcare Organizations. 2004 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH). Oakbrook Terrace, Illinois: Joint Commission on Accreditation of Healthcare Organizations; 2004.
Brennan TA. The institute of medicine report on medical errors – Could it do harm? N
Engl J Med 2000;342:1123-5.
Elder NC, Dovey SM. Classification of medical errors and preventable adverse events in primary care: A synthesis of the literature. J Fam Pract 2002;51:927-32.
Dovey SM, Meyers DS, Phillips RL Jr., Green LA, Fryer GE, Galliher JM, et al.
A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care 2002;11:233-8.
Dovey SM, Phillips RL, Green LA, Fryer GE. Types of medical errors commonly reported by family physicians. Am Fam Physician 2003;67:697.
Kuo GM, Phillips RL, Graham D, Hickner JM. Medication errors reported by US family physicians and their office staff. Qual Saf Health Care 2008;17:286-90.
Glavin RJ. Drug errors: Consequences, mechanisms, and avoidance. Br J Anaesth 2010;105:76-82.
Hickner J, Thompson PJ, Wilkinson T, Epner P, Sheehan M, Pollock AM, et al.
Primary care physicians' challenges in ordering clinical laboratory tests and interpreting results. J Am Board Fam Med 2014;27:268-74.
Balch CM, Oreskovich MR, Dyrbye LN, Colaiano JM, Satele DV, Sloan JA, et al.
Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg 2011;213:657-67.
Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med 2011;365:629-36.
Rubin JB, Bishop TF. Characteristics of paid malpractice claims settled in and out of court in the USA: A retrospective analysis. BMJ Open 2013;3. pii: E002985.
Kraman SS, Hamm G. Risk management: Extreme honesty may be the best policy. Ann Intern Med 1999;131:963-7.
Sage WM. Medical malpractice reform: When is it about money? Why is it about time? JAMA 2014;312:2103-5.
Kmietowicz Z. Doctors facing complaints have severe depression and suicidal thoughts, study finds. BMJ 2015;350:h244.
Wu AW. Medical error: The second victim. The doctor who makes the mistake needs help too. BMJ 2000;320:726-7.
Seys D, Wu AW, Van Gerven E, Vleugels A, Euwema M, Panella M, et al.
Health care professionals as second victims after adverse events: A systematic review. Eval Health Prof 2013;36:135-62.
Unwin E, Woolf K, Wadlow C, Potts HW, Dacre J. Sex differences in medico-legal action against doctors: A systematic review and meta-analysis. BMC Med 2015;13:172.
Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: Preliminary retrospective record review. BMJ 2001;322:517-9.
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.
Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995;163:458-71.
Araoye MO. Sample size determination. Research Methodology with Statistics for Health and Social Sciences. Ilorin: Nathadex Publishers; 2004. p. 115-21.
Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al.
Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71.
Berwick DM, Leape LL. Reducing errors in medicine. BMJ 1999;319:136-7.
Barach P, Small SD. Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting system. BMJ 2000;320:759-63.
Ioannidis JP, Lau J. Evidence on interventions to reduce medical errors: An overview and recommendations for future research. J Gen Intern Med 2001;16:325-34.
Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997;277:312-7.
Britten N, Stevenson FA, Barry CA, Barber N, Bradley CP. Misunderstandings in prescribing decisions in general practice: Qualitative study. BMJ 2000;320:484-8.
Akoria OA, Anamefuna FC. Medication error with artesunate-amodiaquine: Case report and root-cause analysis. Afr J Med Health Sci 2014;13:62-6. [Full text]
Nwasor EO, Sule ST, Mshelia DB. Audit of medication errors by anesthetists in North Western Nigeria. Niger J Clin Pract 2014;17:226-31.
] [Full text]
Khan MH, Abbas A. The importance of clinical pharmacists in health care system. Med Sci 2014;11:80-1.
Ravi SP. Medicines use in primary care in developing and transitional countries: Fact book summarizing results from studies reported between 1990 and 2006. Bull World Health Organ 2009;87:804.
Gallagher TH, Waterman AD, Garbutt JM, Kapp JM, Chan DK, Dunagan WC, et al.
US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients. Arch Intern Med 2006;166:1605-11.
Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 2003;289:1991-7.
Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Disclosing medical errors to patients: Attitudes and practices of physicians and trainees. J Gen Intern Med 2007;22:988-96.
Gallagher TH, Denham CR, Leape LL, Amori G, Levinson W. Disclosing unanticipated outcomes to patients: The art and the practice. J Patient Saf 2007;3:158-65.
Kaldjian LC, Jones EW, Rosenthal GE, Tripp-Reimer T, Hillis SL. An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors. J Gen Intern Med 2006;21:942-8.
McLennan SR, Truog RD. Apology laws and open disclosure. Med J Aust 2013;198:411-2.
Robbennolt JK. Apologies and medical error. Clin Orthop Relat Res 2009;467:376-82.
Guillod O. Medical error disclosure and patient safety: Legal aspects. J Public Health Res 2013;2:e31.
Kachalia A, Kaufman SR, Boothman R, Anderson S, Welch K, Saint S, et al.
Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med 2010;153:213-21.
Gallagher TH, Garbutt JM, Waterman AD, Flum DR, Larson EB, Waterman BM, et al.
Choosing your words carefully: How physicians would disclose harmful medical errors to patients. Arch Intern Med 2006;166:1585-93.
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.
Iloh GUP. Quality of care in Africa: Managing patients' expectations and renewing their confidence in service delivery: The best baseline for calibration in Africa. In: Saldana JR, editor. Quality of Health Care: From Evidence to Implementation. New York: Nova Publishers; 2015. p. 269-90.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]