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Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital

BMJ 2012; 344 doi: (Published 13 March 2012) Cite this as: BMJ 2012;344:e832
  1. R M Wilson, chief medical officer1,
  2. P Michel, director2,
  3. S Olsen, fellow3,
  4. R W Gibberd, conjoint professor4,
  5. C Vincent, professor3,
  6. R El-Assady, technical officer5,
  7. O Rasslan, president6,
  8. S Qsous, director7,
  9. W M Macharia, professor and chair8,
  10. A Sahel, coordinator9,
  11. S Whittaker, chief executive officer10,
  12. M Abdo-Ali, assistant professor11,
  13. M Letaief, professor12,
  14. N A Ahmed, national focal point13,
  15. A Abdellatif, director6,
  16. I Larizgoitia, coordinator 14
  17. for the WHO Patient Safety EMRO/AFRO Working group
  1. 1New York City Health and Hospital Corporation, 125 Worth Street, New York, NY 10013, USA
  2. 2Aquitaine Regional Center for Quality and Safety, Bordeaux University Hospital, France
  3. 3Imperial Centre for Patient Safety and Service Quality, Department of Biosurgery and Technology, Imperial College, London, UK
  4. 4University of Newcastle, NSW, Australia
  5. 5WHO Eastern Mediterranean Region, Cairo, Egypt
  6. 6Egyptian Patient Safety Association, Faculty of Medicine, Ain Shams University, Cairo
  7. 7Ministry of Health, Amman, Jordan
  8. 8Department of Paediatrics, Aga Khan University, Nairobi, Kenya.
  9. 9Quality Management Unit, Ministry of Health, Morocco
  10. 10Council for Health Service Accreditation of Southern Africa, Cape Town, South Africa
  11. 11National Ribat University, Khartoum, Sudan
  12. 12University Hospital of Monastir, Tunisia
  13. 13Ministry of Public Health and Population, Sanaa, Yemen
  14. 14Patient Safety Programme, World Health Organization, Geneva, Switzerland
  1. Correspondence to: R Wilson ross.wilson{at}
  • Accepted 25 November 2011


Objective To assess the frequency and nature of adverse events to patients in selected hospitals in developing or transitional economies.

Design Retrospective medical record review of hospital admissions during 2005 in eight countries.

Setting Ministries of Health of Egypt, Jordan, Kenya, Morocco, Tunisia, Sudan, South Africa and Yemen; the World Health Organisation (WHO) Eastern Mediterranean and African Regions (EMRO and AFRO), and WHO Patient Safety.

Participants Convenience sample of 26 hospitals from which 15 548 patient records were randomly sampled.

Main outcome measures Two stage screening. Initial screening based on 18 explicit criteria. Records that screened positive were then reviewed by a senior physician for determination of adverse event, its preventability, and the resulting disability.

Results Of the 15 548 records reviewed, 8.2% showed at least one adverse event, with a range of 2.5% to 18.4% per country. Of these events, 83% were judged to be preventable, while about 30% were associated with death of the patient. About 34% adverse events were from therapeutic errors in relatively non-complex clinical situations. Inadequate training and supervision of clinical staff or the failure to follow policies or protocols contributed to most events.

Conclusions Unsafe patient care represents a serious and considerable danger to patients in the hospitals that were studied, and hence should be a high priority public health problem. Many other developing and transitional economies will probably share similar rates of harm and similar contributory factors. The convenience sampling of hospitals might limit the interpretation of results, but the identified adverse event rates show an estimate that should stimulate and facilitate the urgent institution of appropriate remedial action and also to trigger more research. Prevention of these adverse events will be complex and involves improving basic clinical processes and does not simply depend on the provision of more resources.


  • AFRO EMRO working group

  • Ossama S Rasslan, Atef Badran, Mahi El-Tehewy, Aisha Aboul Fotouh, Suzan Mohammed (Egypt); Safa Qusous, Mai Rahaleh, Wael Kildani (Jordan); William Macharia, J Mwangi, P Mwella, Janet Butage (Kenya); Amina Sahel, Nabil Kenjaa, Amine Ali Zeggwagh (Morocco); Stuart Whittaker, Fikile Sithole (South Africa); Malik Abdo Ali, Zahir Mohammed Khier Allah, Sara Hassan Mostafa, Hatim Zain Alabdeen Abdul Bari, Al-Khatami Elias (Sudan); Mondher Letaief, Mohammed Salah Ben Ammar (Tunisia); Nasr Ali Ahmed, Adel-Al Moayed (Yemen); Ross Wilson, Philippe Michel, Sisse Olsen (international consultants and principal investigators); Ahmed Abdellatif, Riham El-Assady, Sameen Siddiqi (WHO EMRO); and Itziar Larizgoitia (WHO Patient Safety).

  • We thank all the country teams that participated in the study and Nittita-Prasopa Plaizier from WHO Patient Safety and Hoda El Sabbahy from EMRO for technical and administrative support. We also thank Jean Bosco Ndihokubwayo and WHO colleagues for support and encouragement; Martin Fletcher, G Ross Baker, and David Bates for their advice; and Liam Donaldson for his vision.

  • Contributors: RW, PM, SO, and CV designed and oversaw the conduct of the study, trained the country leads, and drafted the manuscript. RG advised on design and oversaw data collection and performed data analysis. OR, SQ, WM, AS, SW, MA, ML, and NA lead the conduct of the project in each of their countries and reviewed and contributed to the final version of the manuscript. AA was the executive sponsor for the project at the EMRO of WHO and instrumental in establishing the necessary collaborations to conduct the study. IL was the WHO executive sponsor in Geneva, provided advice on the conduct of the study and on the final manuscript. RW is guarantor.

  • Funding: This study was sponsored and funded by WHO. The Northern Centre for Healthcare Improvement of NSW Health was contracted by WHO to conduct the study. RW was the director of the centre, and RG was subcontracted for advice on statistical methods and analysis. Most other authors received support for travel related expenses for the study. The authors employed by WHO received salaries from WHO and travel expenses related to the study.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study went through appropriate ethics review managed by WHO ethics review committee for the Eastern Mediterranean region. Where participating hospitals also have a specific ethics review committee, the study received the local specific approval.

  • Data sharing: French translations of the review forms (RF1 and RF2) are available on request from the corresponding author.

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