Patient Safety Efforts in Tanzania: A Rapid Review of Two-Decades Efforts (2002-2022) to Inform Interventions towards Attainment of 2030 Targets

Joseph C. Hokororo^1*, Michael Habtu², Radenta P. Bahegwa¹, Ruth R. Ngowi¹, Yohanes S. Msigwa¹, Mbwana M. Degeh¹, Erick S. Kinyenje¹, Omary A. Nassoro¹, Laura E. Marandu¹, Chrisogone J. German¹, Edwin Mkwama³, Bushi Lugoba⁴, Grace E. Saguti², Zabulon Yoti², Eliudi S. Eliakimu^1*

¹Health Quality Assurance Unit, Ministry of Health, Dodoma, Tanzania.
²World Health Organization, Dar es Salaam, Tanzania.
³Centre for Distance Education, Morogoro, Tanzania.
⁴Benjamin Mkapa Hospital, Dodoma, Tanzania.

DOI: 10.4236/aid.2022.123036                

Abstract

Introduction: The need to address the problem of patient safety has been a focus of World Health Assembly (WHA) meetings of 2002, 2019 and 2021. The 2019 WHA Resolution urged the Member States to take action on patient safety. We aimed to review patient safety efforts in Tanzania from 2002 to 2022 to inform improvement efforts towards the 2030 target. Methods: A rapid literature review was conducted between January 2002 and April 2022. We searched Google, PubMed and PubMed Central in April and May 2022 using the following search terms: PubMed—“patient safety Tanzania”, “blood safety in Tanzania”, “safe surgery Tanzania”, and “healthcare-associated infections Tanzania”; Google—“blood safety in Tanzania”, injection safety in Tanzania”, “infection prevention and control”, “radiation safety in health facilities in Tanzania”; and PubMed Central—“injection safety in Tanzania. Results: The search identified 4160 articles, of which 4053 were removed in initial screening; 21 were duplicates, giving 86 relevant articles for full screening. Of the 86 articles, 04 were removed after the full screening, hence remaining with 82 articles. Among the 82 eligible articles, 27 are on IPC, 26 on safe surgery, 12 on blood safety, 07 on radiation safety, 06 on injection safety, and 02 on medication safety. One article was relevant to—blood safety, IPC and injection safety; and one article was relevant to—IPC and injection safety. Conclusion: Most of the eligible literature was on IPC and safe surgery, followed by blood safety, radiation safety, injection safety and medication safety. The literature on IPC has highlighted the need to strengthen efforts to address AMR. Findings from the implementation of the safe surgery 2020 intervention warrants for its scale-up to other zones. There is a need to strengthen hemovigilance and pharmacovigilance functions; and strengthen quality management and assurance systems and regulatory functions to ensure radiation safety.

Keywords

Patient Safety, Safe Surgery, Infection Prevention and Control, Medication Safety, Radiation Safety

1. Introduction

In 2002, during the World Health Organization (WHO) Fifty-fifth World Health Assembly (55 WHA), the WHA passed Resolution WHA 55.18 (of 18 May 2002), which urged the Member States to “pay the closest possible attention to the problem of patient safety; and to establish and strengthen science-based systems, necessary for improving patients’ safety and the quality of health care, including the monitoring of drugs, medical equipment and technology” [1]. Following the resolution on patient safety, the WHO continued with the efforts to provide guidance to the Member States in which one of the key actions was the launching of the World Alliance for Patient Safety in October 2004, charged with a core work of driving forward the agenda on patient safety [2]. The work of the Alliance focused on the following areas: “Patients for Patient Safety; Reporting and Learning; Taxonomy; Solutions; Research; and Global Patient Safety Challenge” [3].

The World Alliance for Patient Safety during its lifetime (2004-2014), it had several achievements in the implementation of its roles. [4] In the area of global patient safety challenge, the Alliance launched the first challenge in 2005-2006 under the banner “Clean Care is Safer Care”, aiming at taking actions to reduce healthcare-associated infections worldwide [5] [6] [7]. The second patient safety challenge was “safe surgery saves lives” [8] [9]. In the area of “Taxonomy,” the World Alliance for Patient Safety formed a group to work on “International Classification for Patient Safety.” [2]. In the areas of “Reporting and Learning; and Research”, efforts to assess the literature on measures for patient safety used in “developing and emerging countries” have been done. [10] Also, the Global Alliance in 2010 developed a “patient safety curriculum guide for medical schools” [11]; and in 2011, the Global Alliance developed a “patient safety curriculum guide for multi-professional” [12].

In the years after the life of the World Alliance for Patient Safety (2015-2021), the WHO has moved further to engage with a bigger number of stakeholders and partners in order to be able to improve patient safety globally [4]. One of the early efforts was the launch of the Third Global Patient Safety Challenge, called “Medication Without Harm,” which aimed at addressing medication safety [13] [14]. Also, in the Seventy-second World Health Assembly (72 WHA) in 2019, a resolution on patient safety (Resolution 72.6 of 28 May 2019 on Global action on patient safety) was passed [15].

Also, the “Resolution 72.6 of May 2019—Global Action on Patient Safety” identified clinical programmes and risk areas where the Member States need to focus their patient safety strategies which include: “medication safety, surgical safety, infection control, sepsis management, diagnostic safety, environmental hygiene and infrastructure, injection safety, blood safety and radiation safety.” [15]. The area of infection prevention and control (IPC) in Low- and Middle- Income Countries (LMICs) received attention after the establishment of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 in which 14 countries namely: Botswana, Ethiopia, Guyana, Haiti, Ivory Coast, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia, were supported [16]. Through the PEPFAR support, Tanzania established a National IPC—Injection Safety (IPC-IS) Program in 2004, in which injection safety was given a special attention due to the risks associated with unsafe injections, especially the spread of bloodborne pathogens [17]. In the 1990s, there were widespread practices for the reuse of injection equipment in health care settings worldwide, in 2000 analysis had shown that the reuse of injection equipment contributed to 32%, 40% and 5% of new Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Human Immunodeficiency Virus (HIV) infections respectively [18]. Implementation of Policy interventions on the appropriate use of injection equipment was shown to be cost-effective in addressing the situation [18].

The area of blood safety had received attention since the mid-1970s when the WHO in the Twenty-Eighth WHA in 1975 passed “Resolution WHA 28.72: Utilization and Supply of Human Blood and Blood Products.” [19]. In sub-Saharan Africa (sSA) HIV, which causes the Acquired Immune Deficiency Syndrome (AIDS), was widely reported in the mid-1980s and hence, it affected the safety of blood. A study by Fleming in 1997 reported on contribution of blood transfusion on HIV transmission to be between 10% and 15% [20]. However, more recent modeled estimates have suggested it to be lower, at the estimation of less than 1% [21]. A recent systematic review has raised a need for preventing bacterial contamination of blood products and prevention of “transfusion-associated sepsis” [22]. Despite improvements that have been made by many countries in sSA, there is still a need for more efforts to address challenges in screening for transfusion-transmitted infections (TTIs) [23].

In the Seventy-fourth meeting that was held virtually due to the ongoing global pandemic of Coronavirus disease 2019 (COVID-19), the Seventy-fourth WHA (74 WHA) on its plenary meeting held on 31^st May, 2021 made a key decision on patient safety (Decision WHA 74 (13)) which included: “1) adoption of the Global Patient Safety Action Plan 2021-2030; and 2) a request to the Director-General to report back on progress in the implementation of the Global Patient Safety Action Plan 2021-2030 to the Seventy-sixth World Health Assembly in 2023 and thereafter every two years until 2031.” [24]. Following the decision to adopt the global action plan on patient safety, the WHO, in August 2021 launched the “Global Patient Safety Action Plan 2021-2030,” which contains a 7-by-5 framework (i.e., with seven strategic objectives, each with five specific strategies to achieve it) [4].

Given that adverse events are major health concerns, quantifying the magnitude and characteristics of those events in health provision is necessary to pinpoint research priorities and realistic interventions for patient safety. Therefore, we aimed to conduct a rapid review of adverse events that hamper patient safety. The findings of this study will provide evidence to support the development of priority actions in future research and policies.

2. Methods

We conducted a rapid review (of scientific literature and grey literature) guided by the practical guide for rapid reviews to strengthen health policy and systems [25] of intervention efforts implemented between January 2002 and April 2022. The aim was to understand what interventions related to patient safety have been explored in the literature and their key findings in order to inform the Ministry’s efforts to further improve patient safety towards the attainment of the 2030 global target as envisioned in the Global Patient Safety Action Plan for 2021-2030 [4]. We searched Google, PubMed and PubMed Central using the following search terms: PubMed—“patient safety Tanzania”, “blood safety in Tanzania”, “safe surgery Tanzania”, and “healthcare-associated infections Tanzania”; Google—“blood safety in Tanzania”, injection safety in Tanzania”, “infection prevention and control”, “radiation safety in health facilities in Tanzania”; and PubMed Central—“injection safety in Tanzania.”

The search in Google, PubMed and PubMed Central was done in April and May 2022 as follows: Google (05 & 07 April, 14-16 April, 24-25 April); PubMed (14-16 April; 22 April; 01 May; 07-08 May); and PubMed Central (16-17 April). We limited ourselves to articles and grey literatures published in English between January 2002 and April 2022. We chose 2002 because it is the year when the first resolution on patient safety was passed by the WHA. Articles were included if they focused on any aspect of the patient safety risk programmes and areas, i.e., all aspects of IPC including antimicrobial resistance (AMR); injection safety; blood safety; medication safety; radiation safety; and safe surgery as highlighted in the Resolution 72.6 of May 2019 [15]. Initial screening of the articles was done independently by one author (ESE) and drafted the results. Then, five other authors (JCH, RPB, RRN, YSM, and CJG) screened the draft results for inclusion, and where there were disagreements or omission, it was discussed among the authors (ESE, JCH, RPB, RRN, YSM, and CJG) and agreement reached after resolving the differences.

3. Results

The search identified a total of 4160 articles (published and grey literature), out of which 4053 articles were removed after screening titles and abstracts/content summary, hence the remaining with 107 articles that were relevant for full screening. Out of the 107 articles, 21 were duplicates, and 04 articles were removed after the full screening of the papers; hence remaining with 82 eligible articles were included in the final analysis as shown in Figure 1. Analysis of the 82 articles (77 published literature and 05 grey literatures) on patient safety interventions in Tanzania between January 2002 and April 2022 is shown in Table 1.

Figure 1. Literature search and analysis process.

Table 1. Summary of patient safety articles in Tanzania from January, 2002 to April, 2022.

4. Discussion

The literature on patient safety in Tanzania has covered a lot of issues that can inform ongoing efforts for further improvement. In the area of blood safety, key issues covered include blood donors (focusing on voluntary; non-remunerated donors; their education; increasing their pool through public health-driven iron deficiency anaemia prevention and treatment programmes; and establishing blood conservation policies); TTIs; the need for implementation of international safety standards and quality management systems; establishing reliable country-based funding for compensating the decreased external donor funding; strengthening regulation and control of blood and blood products; as well as, hemovigilance function of national regulatory authority. Also, a need for strengthening clinical evaluation and HBV and HCV risk factors assessment before blood donation; and strengthening IPC-injection safety in national blood transfusion services have been emphasized. The established NBTS through the support of the United States Government in 2004 has been very instrumental towards strengthening of blood safety at all levels of service delivery. Strengthening efforts for accreditation of the Zonal NBTS Centres and implementation of quality management systems coupled with country efforts to ensure the availability of adequate funding is key in maintaining blood safety in Tanzania [108].

In the IPC area, key topics explored include: healthcare-associated infections (HAIs); SSIs, MDR organisms; preventing newborns cord infection and puerperal sepsis; neonatal sepsis with MDR gram-negative bacteria; Impact of training on practice change; MRSA nasal carriage rate among HCWs; MRSA contamination among various items in patients’ care surroundings; adherence to IPC principles in primary health care facilities; bloodstream infections with MDR bacteria; compliance of HCWs in outpatient settings of private and faith-based health facilities to IPC principles; compliance with hand hygiene; ICU nurses’ knowledge, compliance, and barriers toward EBGs for prevention of VAP; Educational intervention for improving environmental hygiene; compliance to IPC standards in health facilities; criterion-based audit on IPC and knowledge during vaginal delivery at a hospital; hand hygiene compliance and level of microbiological contamination of hands of HCWs; sources of MDR bacteria for among orthopaedic patients.; CA-UTI among patients with long-term and short-term indwelling urinary catheterization. The prominence of MDR bacteria in the literature is in line with the recent global report on burden bacterial AMR in 2019 [109]; hence, strengthening IPC interventions is critical at all levels of service delivery in Tanzania. The burden of AMR also requires concerted efforts across many sectors; therefore, the lessons learned so far on improving multisectoral coordination need to be sustained and further explored to inform on the best practices [110]. Prevention of HAIs in neonatal units in Tanzania can also benefit from the implementation of “the 3 + I Classification Framework” which consists of “1) Primary prevention, 2) Detection, 3) Case management, and Implementation (3 + I)”, as put forward by Molina García and colleagues [111].

Injection safety practices have improved significantly in the past two decades. Key aspects explored in the literature include the number of injections per person; unsafe injections and nosocomial bloodstream infections; knowledge of injection safety practices; use of unopened syringe or needle; access to new syringe and needle; canulation procedure; strengthening injection safety in national blood transfusion services; safe disposal of sharps wastes; storage of sharps waste; and availability of auto-disable syringes. Medication safety is the least explored area in which the literature has focused on: pharmacovigilance systems and reporting of adverse drug reactions, as well as an analysis of the strengths and limitations of the national pharmacovigilance systems.

Radiation safety focused on the following: quality control and preventive maintenance of diagnostic X-ray machines; quality control implementation by radiographers; optimization of radiation protection using simple and inexpensive techniques, and lack of Medical Physicists as one of the challenges affecting radiation safety; high radiation dose rates recorded at viewing windows, walls and doors of control cubicles and behind the doors of changing cubicles (risking workers and external clients); capacity building of staff from health facilities to enable them to provide quality services, and ensure quality radiation care with high precautions being taken to reduce the potential hazard from radiation exposure, which was organized by TAEC; and a need for enhance collaboration, training and research, and investing in technologies like machine learning and artificial intelligence in order to catalyze radiation quality and safety. The good work done by the Tanzania Government in expanding the training of required human resource is commendable and need to be coupled with the implementation of quality management and assurance systems to ensure the safe use of radiation technologies and strengthening national regulatory system to ensure safety in collaboration with the International Atomic Energy Agency [112].

Safe surgery has been extensively explored in the literature covering all the key topics such as: introduction of the WHO Surgical Safety Checklist use in operating rooms; outcomes of procedures performed by NPCs as compared to physicians; knowledge and attitudes of anaesthetists towards use of the WHO surgical checklist; capacity to provide safe anesthetic care for mothers; Health facilities meeting the three readiness indicators for performing caesarean sections in Tanzania in 2014-15; Safe Surgery 2020 intervention implementation in Lake Zone, which aimed at increasing adherence to surgical quality processes around safety, teamwork and communication, data quality, and reduce complications from SSI, postoperative sepsis, and maternal sepsis; development process and outcome of the National Surgical, Obstetric and Anesthesia Plan in Tanzania; impact of education and training of HCWs on sterile processing practices; strengthening capacity of hospitals at district level to provide safe surgery through quarterly supportive supervision by Specialists from referral hospitals, and using mobile phones to provide phone consultations with surgical providers; capacity of hospitals at district level to provide anesthesia using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) index score; health facilities infrastructure and provision of CEMONC services; data quality and record keeping in documentation of SSI and sepsis for improving surgical team communication, continuity of care, and patient safety; relaparotomy and mortality rate; impact of implementation of surgical monitoring and quality control systems at district hospitals; development and validation of content of “Safe Surgery Organizational Readiness Tool”; and assessment of outcome of a Paediatric ENT Skills and Airway Course.

Guided by HSSP V and its costing, the Tanzania Ministry of Health plans to develop and implement National Patient Safety Guideline; [113] [114] as part of complying with the requirement from the 72 WHA [15] and the 74 WHA [24] as well as the WHO Global Patient Safety Action Plan. [4] The Ministry will also work to establish a system for incident reporting as well as a procedure for analysis of incident reports in order to enable health facilities and health management teams at all levels to learn from incidents and hence set strategies to prevent their recurrence [115].

Tanzania can also benefit from continued implementation of the “5S-KAIZEN-TQM approach” in health facilities as a foundational intervention of quality improvement efforts in health facilities given its potential to improve safety in general including its contribution to improvement in cleanliness and health care waste management in health facilities [116] [117] [118].

The study has the following two limitations: first, we have searched the following databases—PubMed, PubMed Central, and Google; therefore, we may have missed some other literature that is published in journals that are not indexed in PubMed and PubMed Central. Secondly, the aim of the rapid review was to identify the literature on patient safety in Tanzania in terms of its key findings and issues in order to inform future improvement steps; in the execution of the review, we may not have adequately fulfilled all the steps but we believe we have tried to the best to be comprehensive and transparent as possible in the process [119]. The results obtained are adequate for informing and understanding of patient safety efforts in the past two decades (2002-2022); and hence, can contribute to future efforts to ensure patient safety in Tanzania for the period 2022-2030.

5. Conclusion

In the past two decades (2002-2022), a lot of efforts have been done to ensure patient safety in Tanzania, as evident from the rapid literature review. Most of the identified literature was on IPC and safe surgery, followed by blood safety, radiation safety, injection safety and medication safety. The literature on IPC has highlighted the need for further strengthening of the efforts to address AMR. The results of the implementation of the safe surgery 2020 intervention in Lake Zone were promising; therefore, the Ministry of Health needs to consider scale-up of its implementation to other zones taking into account the lessons learned. The hemovigilance function and pharmacovigilance functions by the TMDA need to be strengthened to ensure blood safety and medication safety respectively. Strengthening the implementation of quality management and assurance systems to ensure the safe use of radiation technologies, as well as strengthening national regulatory system (through the TAEC) in collaboration with the International Atomic Energy Agency is essential for radiation safety.

Acknowledgements

The authors would like to thank all the authors of the articles and grey literature that have been used to inform the development of the manuscript. Also, on a special note, the authors would like to thank WHO for the technical guidance they are providing in Tanzania to ensure patient safety interventions, especially IPC are well implemented.

Authors Contributions

ESE—conceptualization of the manuscript, article searching, data extraction and initial drafting of the manuscript;

JCH—drafting the manuscript, checking and approval of article searched and data extraction; RPB drafting the manuscript, checking and approval of article searched and data extraction;

RRN—drafting the manuscript, checking and approval of article searched and data extraction;

YSM—drafting the manuscript, checking and approval of article searched and data extraction;

CJG—drafting the manuscript, checking and approval of article searched and data extraction; and

All authors read, contributed and improved all versions of the manuscript including approval of the final version for publication.

Disclaimer

The contents of this article represent the views of the authors and do not necessarily reflect the views of the organizations with which the authors are affiliated.

NOTES

*Joint first author.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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