title: Why is patient safety so hard in low-income countries? A qualitative study of healthcare workers' views in two African hospitals.
abstract: BACKGROUND
  The views of practitioners at the sharp end of health care provision are now recognised as a valuable source of intelligence that can inform efforts to improve patient safety in high-income countries. Yet despite growing policy emphasis on patient safety in low-income countries, little research examines the views of practitioners in these settings. We aimed to give voice to how healthcare workers in two East African hospitals identify and explain the major obstacles to ensuring the safety of patients in their care.
  
  
  METHODS
  We conducted in-depth, face to face interviews with healthcare workers in two East African hospitals. Our sample included a total of 57 hospital staff, including nurses, physicians, technicians, clinical services staff, administrative staff and hospital managers.
  
  
  RESULTS
  Hospital staff in low-income settings offered broadly encompassing and aspirational definitions of patient safety. They identified obstacles to patient safety across three major themes: material context, staffing issues and inter-professional working relationships. Participants distinguished between the proximal influences on patient safety that posed an immediate threat to patient care, and the distal influences that generated the contexts for such hazards. These included contexts of severe material deprivation, but also the impact of relational factors such as teamwork and professional hierarchies. Structures of authority, governance and control that were not optimally aligned with achieving patient safety were widely reported.
  
  
  CONCLUSIONS
  As in high-income countries, the accounts of healthcare workers in low-income countries provide sophisticated and valuable insights into the challenges of patient safety. Though the impact of resource constraints and weak governance structures are particularly marked in low-income countries, the congruence between accounts of health workers in diverse settings suggest that the origins and solutions to patient safety problems are likely to be similar everywhere and are rooted in human factors, resources, culture and behaviour. While additional resources are essential to patient safety improvement in low-income settings, such resources on their own will not be sufficient to secure the changes needed.
authors.affiliation: SAPPHIRE Group, Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK. eea5@le.ac.uk.|Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA. eea5@le.ac.uk.
authors.forename: Emma-Louise
authors.initials: EL
authors.lastname: Aveling
authors.affiliation: Department of Welfare and Social Development, Catholic University of Rwanda, Huye, Rwanda. kayongayvette1@gmail.com.
authors.forename: Yvette
authors.initials: Y
authors.lastname: Kayonga
authors.affiliation: Institute of Public Health, University of Gondar, Gondar, Ethiopia. aish262000@gmail.com.
authors.forename: Ansha
authors.initials: A
authors.lastname: Nega
authors.affiliation: SAPPHIRE Group, Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK. md11@le.ac.uk.
authors.forename: Mary
authors.initials: M
authors.lastname: Dixon-Woods
mesh_terms: D000351:Africa, Eastern; D006801:Humans; D007407:Interviews as Topic; D008505:Medical Staff, Hospital / Q000523:psychology*; D061214:Patient Safety; D036301:Qualitative Research