Exploring medication error causality and reporting in the Middle East.

The "Medication Without Harm, WHO Global Patient Safety Challenge", published by the World Health Organization in 2017, calls for action to reduce patient harm as a result of unsafe medication practices and medication errors. Medication error-related research conducted within the Middle East has been noted to be of poor quality. The aim of this thesis was to investigate issues relating to medication error causality and suboptimal reporting of medication errors, with the intention of contributing to the development of theory-informed interventions. The first phase was a PROSPERO-registered systematic review, which aimed to critically appraise, synthesise and present the available evidence around the incidence/prevalence, nature and causes of medication errors among hospitalised patients in Middle Eastern countries. Findings indicated the lack of robust and rigorous research, both generally and also specifically in Qatar. There was a clear need for theory-informed primary research. The second phase collated data recorded in medication error reports submitted within Hamad Medical Corporation (HMC), Qatar. The estimated incidence of medication errors in HMC (as derived from medication error reports) was 0.44 per 1,000 medication orders, which is lower than previous studies published in the region and elsewhere. According to Reason's Accident Causality Model, the vast majority were considered as active failures (i.e. slips, lapses, mistakes and violations). One further key finding was that the reports featured a lack of details, hence limiting any synthesis and conclusions. Notably, behaviour change theories could not be applied and so specific targeted research was warranted. The third phase comprised qualitative focus groups with samples of health professionals in HMC, to explore the perspectives of health professionals on issues of medication error causes, contributory factors and error reporting. The thesis suggests that the following Theoretical Domains Framework (TDF) determinants are potentially associated with these errors: social/professional role and identity; emotions; and environmental context and resources. There was a lack of recognition of nurses' roles and frequent policy non-adherence. Stress was perceived to be a major contributor to errors, as was excessive workload and lack of staff at key times. Discussions on issues of medication error reporting identified a number of facilitators and barriers. The TDF domain of emotions featured heavily, with several key themes emerging as barriers to reporting: fear and worry; concern about an investigation that would likely follow reporting; and concern about the impact on evaluation and appraisal processes. This doctoral research has generated original findings that can be used as part of intervention development, aiming to improve medication safety and optimise medication error reporting systems. Future work should now focus on the feasibility/piloting phase of the Medical Research Council guidelines on complex interventions