Table 3

Factors contributing to patient safety concerns

ThemesParticipant statements
Human (staff) factors
Lack of patient safety competency
 Knowledge‘Sometimes the medication errors usually happen because they [staff] aren’t aware of the right method to be given. For example, there are some medications like [name of drugs withheld] which are really painful and it should not be given direct bolus, but it should rather be given as infusion. […] It so happens that they are given bolus and then we have to be facing a problem and solving it.’ (Nurse—NGM5)
 Skills‘One issue is—usually the patients are seen in […] OPD [Out-patient Department] and they are sent here [to the ward]. So they [clinicians] did not monitor the vital signs and then we had some incidents. […] [one patient] did not have vital signs monitored and did not have [Blood Pressure checked]— actually the patient was ‘walking dead’. Then we had to manage here in the ward and then ultimately send to ICU.’ (Ward manager)
 Attitudes‘It is the attitude [of healthcare providers] sometimes.’ (Ward manager)
‘If I have to say, I think certain procedures are done by people who are not very cautious about taking precautions. For example, as a medical student we knew that we have to take lots of precaution even to insert a catheter but now I see that it is being done very casually. I don’t think people are really taking care of the proper sterile techniques and all.’ (Medical doctor)
System (organisational) factors
Lack of resources‘Contribution for medication error maybe due to the shortage of nursing staff where while they are preparing the medicine, they have to go and attend the other critical cases, if any.’ (Senior manager)
‘I think the most common patient safety issue is establishing diagnosis. I find it as a major issue because patients are not properly followed up and then adequate investigating facilities are not available and we lose patient in between.’ (Nurse)
Lack of policies, guidelines and protocols on patient safety‘One is the standard management of patient. That depends on individual specialists and individual doctors. A major crux of the thing is how to come to a proper diagnosis and what line of treatment. So, highly qualified specialists have their own line of management which some specialists don’t agree.’ (Senior manager)
Poor communication and collaboration‘When I talk about the patient safety one thing is that there is a gap in between doctors and nurses because they prescribe antibiotics and it goes more than 20 to 30 days. […] Doctors, when they prescribe the drugs in ward, most of the doctors they use [name of drugs withheld] which is a 3rd generation antibiotic and they do not write the specific days, like for this many days.’ (Nurse)
‘As of now we have a problem in getting all departments together to get a good care of the patient. For example, in the emergency we see lot of cases which need to be consulted with different departments—interdepartmental consultation. […] But at the moment it is very difficult to have an interdepartmental consultation.’ (Ward manager)
Lack of management support and governance‘Patient safety in Bhutan, in my honest opinion, there isn’t anything happening. We have some visiting professors and we have some health volunteers, they come in and they try to suggest and our staff, one or two maybe, try to take initiatives or people who have seen other hospital they think we need to do something. But it is ailing, because the system is not ready to accept anything. Right now, the health system is only considered about getting drugs and how many beds we can put and how many staff we can recruit but there is no check on how safe are the patients.’ (Nurse)
Poorly developed patient safety incident reporting‘I think that [incident reporting] is the weakest in the health system here. Keeping the data and then recording and reporting is very, very poor in the healthcare system—be it in National Referral Hospital or District Hospitals.’ (Medical doctor)
Lack of patient education on patient safety‘I think in the hospital settings when we talk about safety of the patient and the factors, basically patients were not educated on infection control so thereby they are not able to take care of their own secretions like sputum or urine or even blood. So that is one factor that we are likely to have infections.’ (Health assistant)