ISSN 2394-7330

International Journal of Novel Research in Healthcare and Nursing

Vol. 10, Issue 2, pp: (16-24), Month: May - August 2023, Available at: www.noveltyjournals.com

Assessment of Patient Safety in Accredited and

Non- Accredited Primary Healthcare Units: A
Comparative Study
1
Samia Mohammed Abdalla Madkour, 2Nadia Hassan Ali Awad,
3
Neamat Mohamed El Sayed
1
Nursing Inspector, Nursing Administration, Faculty of Nursing, Damnhour University
2
Assistant Professor, Nursing Administration, Faculty of Nursing, Alexandria University
3
Professor, Nursing Administration, Faculty of Nursing, Damnhour University
DOI: https://doi.org/10.5281/zenodo.7965735
Published Date: 19-May-2023

Abstract: Background: Attention to patient safety and its effect on both individual patient outcomes, and the
healthcare industry as a whole are rendered as one of the most important organizational success in achieving the set
goals. So, developing and retaining patient safety policies and procedures is one of the biggest challenges facing
health care organizations. Patient safety in primary health care (PHC) units is important for all healthcare providers
and patients/ clients of health care organizations, especially staff nurses, where their job performance is affected by
them. Aim: Compare patient safety in accredited and non-accredited PHC units, in Housh Isa City, El Beheira
Governorate Settings: The study was carried out in all accredited and non-accredited PHC units in Housh Isa City,
El Beheira Governorate. It includes 25 PHC units divided into; 18 accredited PHC units, and 7 non-accredited PHC
units. Subjects: The sample divided into two groups as follow: 1. The health care providers in the previously
mentioned settings were 225 out of 428. It was a total of 162 healthcare providers from accredited PHC units and
63 from non-accredited PHC units. The chosen healthcare providers were selected using the bowl technique.
Accordingly, from each PHC unit, two nurses, one physician, one dentist, one pharmacist, one paramedical staff,
one housekeeper, one health educator, and one maintenance staff were chosen. 2. Patients/ clients sample size will
be 400 out of 42708 by equal allocation 16 patients/ clients from each of 25 PHC units based on the patients/clients
visited in the previous 3 months. Tool: One tool was used, The National Safety Requirements (2018) for Units.
Results: The study showed that the accredited PHC units had higher total domain (A) the general patient safety
standards and domain (D) the environmental safety standards than those of the non-accredited PHC units with a
statistically significant difference between them. Conclusion: There was a statistically significant difference between
the accredited and non-accredited PHC units concerning the total patient safety standards mean scores.
Recommendations: Healthcare providers should follow organizational policies, rules, and regulations regarding
patient safety standards. Also, attend specific meetings, workshops, training programs, and seminars held that will
help in improving their performance. The healthcare providers' Managers should enhance the healthcare providers'
participation in the assessment and evaluation of their PHC unit to identify their defects and to be able to pinpoint
issues or concerns to create an action plan for improvement.
Keywords: Healthcare providers, Primary Health Care, Patient Safety, Accreditation.

1. INTRODUCTION
Ensuring patient safety in primary or ambulatory care setting poses a unique challenge for both the health care providers
and the patients (Lawati et al., 2018). Patient safety is defined as the prevention of errors and adverse effects to patients
associated with health care’ and ‘to do no harm to patients (World Health Organization, 2019). Failure in PHC contributes
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to the burden of unsafe care, half the burden of patient harm originates in primary and ambulatory care, about 80% of that
harm can be avoided in PHC settings. It is important to keep patient safe throughout any healthcare setting (World Health
Organization, 2017).
Globally, each year millions of patients are suffering from disabilities, injuries, or death as a result of unsafe medical
practice, this leading to the wider recognition of the importance of patient safety and to be in the center of the strategic plans
of healthcare organizations (Lawati et al., 2018). The medical errors had been reported to be the third leading cause of death,
but the frequency and severity in the primary health care settings are unknown, so that all staff must understand their role
in prevention. It is estimated that between 5% and 10% of expenditure on health is due to unsafe practices that result in
patient harm (Safety, W. P., & World Health Organization, 2010; Gould, 2017). Unsafe care affects around 10% of patients
most of it was preventable (Webair et al., 2015).
PHC is defined as an essential care based on practical, scientifically sound and socially acceptable methods and technology.
PHC made health care universally accessible and acceptable to individuals, through full participation and at a cost the
community and the country can afford. It provides better health services for all (Al-Assaf & Sheikh 2004); Barkley et al.,
2020). It has been reported that as many as 20‑25% of the general population experience harm in primary care settings in
both developing and developed countries. Various factors that contribute towards poor patient safety in PHC settings include
errors in communication breakdown, diagnosis, unsafe medication practices and fragmentation of care (Macedo et al., 2020;
Lai et al., 2020).
There are a range of strategies are needed that can bring improvement in patient safety in primary care settings; By engaging
patients and families, Medication Reconciliation, and Sharing Information. Also, there are four evidence‑based strategies
that promote meaningful engagement with patients and families in ways that improve patient safety. Be prepared to be
engaged, Create a safe medicine list together, Teach‑Back, and Warm Handoff Plus (Raimondi et al., 2019; Alboksmaty et
al., 2021).
Nurses play a critically important role in ensuring patient safety while providing care directly to patients (Halcomb et al.,
2019). Training, education level and clinical experiments are important factors that influence nurses' perceptions of patient
safety culture. Nurses' knowledge and perceptions of patient safety culture correlate with the era of hospital accreditation
and provide some input for improving the quality of hospital services (Chaneliere, 2018).
Aim of the Study
This study aims to compare patient safety in accredited and non-accredited PHC units, in Housh Isa City, El Beheira
Governorate.
Research Question
Is there difference in patient safety between accredited and non-accredited primary healthcare units, in Housh Isa City, at
El Beheira Governorate?

2. MATERIALS AND METHOD

Materials
Design: A descriptive comparative research design was used to conduct this study.
Settings: The study was carried out in all accredited and non-accredited PHC units in Housh Isa City, El Beheira
Governorate. It includes 25 PHC units divided into; 18 Accredited PHC units namely; Okasha, Harara, Frhash, Elganbiehy,
Abo El Shoqaf, El Abqaen, El Kom El Akhader, El Rozimat, Kafr Elwaq, ElQaza, ElQony, Emara, Kobry Abd, Nagieb
Mahfoze, Mohamed Refat, Abass El Aqad, Abd Elmonaem Riad, and Maternal and Child Health Center (MCH), And 7
Non-accredited PHC units namely; ELhadad Elbahary, Abo Fereen, Tawfik Elhakeem, Ali Ben Aby Talb, El Sheashaay,
Abd Elmegeed Seleem, and El Stomaa.
Subjects: The sample divided into two groups as follow: 1.The health care providers in the previously mentioned settings
were 225 out of 428. It was a total of 162 healthcare providers from accredited PHC units and 63 from non-accredited PHC
units. The chosen healthcare providers were selected using the bowl technique. Accordingly, from each PHC unit, two
nurses, one physician, one dentist, one pharmacist, one paramedical staff, one housekeeper, one health educator, and one
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maintenance staff were chosen. 2. Patients/ clients sample size will be 400 out of 42708 by equal allocation 16 patients/
clients from each of 25 PHC units based on the patients/clients visited in the previous 3 months.
Tools: In order to collect the necessary data for the study one tool was used:
The National Safety Requirements (NSR) for Units: This tool was developed by General Authority for Healthcare
Accreditation and Regulation (GAHAR) (GAHAR, 2018). This tool was used to assess safety in the PHC units. The tool
was classified into four groups (A, B, C, and D) with total of 24 main standards, 40 sub-standards, and 57 items; as follow:
Group A: General Patient Safety Standards, it includes 6 main standards, 5 sub-standards with 10 items. Group B:
Medication Management Safety Standards, it includes 6 main standards, 5 sub-standards with 10 items. Group C: Surgical
Procedure Safety Standards, it includes 4 main standards, 3 sub-standards with 6 items. Group D: Environmental Safety
Standards, it includes 8 main standards, 27 sub-standards with 31 items.
The response was measured on met, partially met, or unmet the higher score was indicate higher patient safety. The score
ranges from met =2 to unmet = zero. A unit had to score 80% or more in each group separately and a total of 90% or more
in all groups to pass the NSR evaluation.
In addition, a demographic characteristics data sheet of the study subjects was developed, it included questions related to
age, gender, educational qualifications, working unit years of nursing experience, years of unit experience, and marital
status.
Method
Approval of the ethics committee of the faculty of nursing was obtained. An official approval to conduct this study was
obtained after providing explanation of the aim of the study. An informed consent was obtained from the healthcare
providers and patients/clients. The study tool was tested for content validity by 5 experts in the field of the study. The
necessary modifications were done accordingly. A pilot study was carried out on 10% of the study sample in order to test
the clarity and applicability of the research tool. Reliability of the tool was tested using Cronbach's Alpha test. The
reliability coefficient was 0.790 which is acceptable.
Data was collected by the researcher during the period from 20/4/2021 to 25/10/2021 each PHC unit took about 2- 3 days.
It took a period of slightly more than 6 months. Concurrent audit was utilized for data collection through; reviewing
documents, observation, and structured interview according to the standard form.
Ethical considerations:
Written informed consent was obtained from patient after explaining the aim of the study and the right to refuse to participate
in the study and/ or withdraw at any time. Patient's/client's privacy was respected. Data confidentiality and anonymity
regarding data collection was maintained during implementation of the study.
Statistical Analysis
The collected data were organized, tabulated and statically analyzed using the statistical package for social studies (SPSS)
Version 20 Qualitative data were described using number and percent. Statistical analysis tests, which included: X2 Chi
square test, student T test and ANOVA test.

3. RESULTS
Table 1 revealed the comparison between the studied accredited and non-accredited PHC units according to the mean scores
of patient safety standards. It showed that there is a statistically significant difference between the accredited and non-
accredited PHC units t=3.155, P=0.004 in relation to the total patient safety standards mean scores (251.17±14.99,
227.14±22.00 respectively).
Table 2 illustrates the comparison between the studied accredited and non-accredited PHC units according to the
compliance of patient safety standards. It was noticed that all the accredited and non- accredited PHC units were partially
met in the total patient safety standards. It showed that all accredited and non-accredited PHC units were partially met in
domain A the general patient safety standards. But, all of them were fully met in both domain B the medication safety
management and domain C surgical procedure safety standards. On the other hand, all accredited PHC units were fully met
in domain D the environmental safety standards, while all non- accredited PHC units were partially met.
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Table 3 revealed the relationship between the studied health care providers’ demographic characteristics and the mean
scores of total patient safety standards in the accredited and non-accredited PHC units at Housh Isa. There is a statistically
significant difference between accredited and non-accredited PHC units patient safety standards mean scores in relation to
the health care providers, age t= 11.688, P= 0.000. A statistically significant difference between the accredited and , non-
accredited PHC units patient safety mean scores in relation to the healthcare providers gender (f = 36.694, P= 0.000). A
statistically significant difference between them in relation to the healthcare providers , marital status (t = 23.540, P= 0.000).
A statistically significant difference was noticed among the accredited and the non-accredited PHC units' patient safety
mean scores in relation to their years of experience since graduation (t= 10.660, P= 0.000). A statistically significant
difference among the accredited and the non-accredited PHC units' patient safety mean scores in relation to their years of
experience in the working units (t= 11.807, P= 0.000).

4. DISCUSSION
This current study is related to the assessment of patient safety in accredited and non-accredited PHC units; comparative
study. In this respect, the results of the present study revealed that the relation between the studied accredited and non-
accredited PHC units according to the mean scores of patient safety standards has a statistically significant difference
between the accredited and non-accredited PHC units in relation to the total patient safety standards mean scores. This may
be explained as PHC units with accredited designs applying regulations, and policies related to the general patient safety
standards, medication management safety standards, surgical procedure safety standards, and environmental safety
standards.
This agreed with (Al Khenizan & Show, 2011) they showed that, accreditation of PHC units has a positive effect on patient
safety and the continuation of performance according to the accreditation standards compared with non-accredited PHC
units. Also, this agreed with (Al Tehewy et al., 2009) in Egypt, indicating that the accredited units showed a higher degree
of compliance with clinical safety standards compared with the non-accredited units. In the same line, (Chaneliere et al.,
2018) stated that the accreditation process can reduce the incidence of patient safety incidents at Accredited Public Health
Centers as evidenced by the higher frequency of patient safety incidents at non-accredited Public Health Centers. This is
because accredited clinic have conducted assessments during the accreditation process, especially in the chapter of Service
Quality and Patient Safety which includes responsibility, understanding, measurement, and improvement of clinical service
quality and patient safety.
The current study, domain (A) the general patient safety standards, the accredited PHC units had a higher total domain (A)
mean scores than those of the non-accredited PHC units, with a statistically significant difference between them. This agreed
with a study done by (Saut et al., 2017) in Brazilian healthcare organizations. The results suggest that accreditation
contributed to implementing and performing patient safety activities, quality management activities, quality-related policy
and strategy planning and involvement of professionals in quality programs.
A higher total domain (B) medication management safety mean scores were found in the accredited PHC units compared
to the non-accredited PHC units. This is because the accredited PHC units applying Policy and procedure for medication
management safety, abbreviations not to be used throughout the organization, implementing a process to obtain and
document a complete list of patient's current medications upon assessment and with the involvement of the patients, labeling
all medications, medication containers e.g. syringes, medicine cups, basins or other solutions, and identifying high risk
medications, storage and dispensed to assure that risk is minimized.
This agreed with (Alomi et al., 2019); AlKhashan et al., 2021) in the Kingdom of Saudi Arabia, they showed that the
medication administration safety was inadequate at non-accredited PHC units while acceptable at accredited PHC units; so
targeting drug standardization, storage, and distribution with emphasis on medication device use and monitoring are highly
recommended for non-accredited PHCs in the Kingdom of Saudi Arabia. Moreover the accreditation model of the Kingdom
of Saudi Arabia, in PHCs uses the consolidated approach and is approved by ISQua, encompasses departmental domains
such as laboratory services, radiology, and medication.
According to domain (C) the surgical procedure safety standards, it was the same in both the accredited and non-accredited
PHC units; there was no difference between the accredited and the non- accredited primary healthcare units in domain (C)
the surgical procedures safety standards mean scores. This is because both following the policy and procedures for surgical

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procedures safety, the precise site where the surgery will be performed is clearly marked by the physician with the
involvement of the patient, a checklist is developed and used to verify that all documents and equipment needed for surgery
or invasive procedure are on hand, correct, and functioning properly before the start of the surgical procedure, and there is
a documented process of accurate patient identification preoperatively and just before starting a procedure (time out), to
ensure the correct patient, procedure, and body part.
This agreed with( Bernan et al., 1991) who clarified that, surgical errors, many of which are preventable, result in reduced
patient safety during perioperative care and while the patient is under the responsibility of the surgical team. Also, (Welch
et al., 1998) clarified that, the quality of surgical care is often constrained by lack of trained staff, poor facilities, inadequate
technology and limited supplies of drugs and other essential materials. So, the priorities in resource allocation should be on
evaluation and implementation of basic measures of hygiene and maintenance of instruments, education and training of
nurses and surgeons on safe practices.
According to domain (D) the environmental safety standards in the current study, there is a statistically significant difference
between the accredited and the non-accredited PHC units. The accredited PHC units had a higher total domain (D) mean
scores than those of the non-accredited PHC units. This is because most of the accredited PHC units have a well-structured,
implemented fire and smoke safety plan that address prevention, early detection, response, and safe exit when required by
fire or other emergencies, also a well-structured and implemented safety and security plan/s, well-structured and functioning
laboratory safety program, a well-structured and implemented plan for selecting, inspecting, maintaining, testing, and safe
usage of medical equipment and essential utilities. These measures are perceived to contribute toward better outcomes.
This agreed with (Beaumont, 2002) in Paris, clarified that accreditation was linked to a safer environment for patients and
staff, better management in planning and provision of services based on population health needs, evidence-based decision-
making, and continuous learning and improvement. In the same line, (Najjar et al., 2013) in Palestine, and (El-Jardali et al.,
2014) in Saudi Arabia, a punitive safety environment was reported to be an area for improvement in accredited PHC. The
evidence of a correlation between the accreditation status and quality management activities supported the vision of
accreditation as an important quality management model. Again, (Sevilla-Zeigen, 2016) illustrated that healthy work
environment improves patient safety.

5. CONCLUSION
Based upon the findings of the current study, it could be concluded that there is a statistically significant difference between
the accredited and non-accredited PHC units concerning the total patient safety standards mean scores. Regarding domain
(A) the general patient safety standards and domain (D) the environmental safety standards, the accredited PHC units had
higher total domain than those of the non-accredited PHC units with a statistically significant difference between them.
Additionally, there was no difference between the accredited and the non-accredited PHC units in domain (C) the surgical
safety procedures standards mean scores.

6. RECOMMENDATIONS
In line with the findings of the study, the following recommendations are made:
I. The PHC unit managers should:
- Develop strategies to improve general patient safety standards through:
a- Empower and motivate healthcare providers by increasing financial benefits, rewards, and recognition of their work.
b- Contribute to change by creating increased awareness for all healthcare providers to ensure appropriate error-preventing
procedures and systems in the healthcare environment.
c- Creating an environment that addresses and prevents potential or actual safety problems that can help to reduce the
incidence of medical errors by healthcare providers in the workplace.
II. The healthcare providers' Managers:
1- Obtaining feedback from healthcare providers and patients/ clients will allow gaining insight into process improvement
techniques, improved learning, teamwork, and communication skills in the healthcare system.
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2- Enhance the healthcare providers' participation in the assessment and evaluation of their PHC unit to identify their defects
and to be able to pinpoint issues or concerns to create an action plan for improvement.
3- Provide opportunities for growth and development of the healthcare providers' abilities, through attaining training
programs for general patient safety standards and encouraging self-learning and updating of their knowledge.
III. The healthcare providers should:
1- Attend specific meetings, workshops, training programs, and seminars held that will help in improving their performance.
2- Follow organizational policies, rules, and regulations regarding patient safety standards.
3- Cooperate and communicate openly with each other and with their managers to discuss obstacles that are facing them
when applying their work and ways for improvement to achieve a high level of patient safety.
Table (1): Comparison between the studied accredited and non-accredited PHC units according to the mean scores
of patient safety standards (n=25 PHC units).

Accredited PHC units Non-accredited PHC units

(n=18) (n=7) Test of Sig.
Items
Mean ± SD Mean ± SD

75.43±5.912
79.50±3.167 t=2.247
A. General Patient Safety Standards
P=0.034*
B. Medication Management Safety 53.39±2.253 52.86±1.952 t=0.546
Standards P=0.590
18.00±0.000 18.00±0.000 NA
C. Surgical Procedure Safety Standards
100.28±13.95 80.86±16.69 t=2.963
D. Environmental Safety Standards
P=0.007*
t=3.155
Total Patient Safety Standards 251.17±14.99 227.14±22.00
P=0.004*

t = Student T Test * Statistically significant at p ≤ 0.05

NA: Not Applicable; can't make the test of significance because the two is the same.
Table (2): Comparison between the studied accredited and non-accredited PHC units according to the compliance
of patient safety standards (n=25 PHC units).

Accredited PHC units Non-accredited PHC

Items (n=18) units (n=7) Test of Sig.
No. % No. %
A. General Patient Safety Standards
- Full met 0 0.0 0 0.0
- Partially met 18 100 7 100 NA
- Not met 0 0.0 0 0.0
B. Medication Management Safety Standards
- Full met 18 100 7 100
- Partially met 0 0.0 0 0.0 NA
- Not met 0 0.0 0 0.0
C. Surgical Procedure Safety Standards
- Full met 18 100 7 100
NA
- Partially met 0 0.0 0 0.0

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- Not met 0 0.0 0 0.0

D. Environmental Safety Standards
- Full met 18 100 0 0.0
- Partially met 0 0.0 7 100 NA
- Not met 0 0.0 0 0.0
Total Patient Safety Standards
- Full met 0 0.0 0 0.0
- Partially met 18 100 7 100 NA
- Not met 0 0.0 0 0.0

NA: Cannot be computed because the expected frequency is less than 5 in more than 20% of the cells.
Table (3): Relationship between the studied health care providers’ demographic characteristics and the mean
score of patient’s safety standards in the accredited and non-accredited PHC units (n=225).

Mean Score of Patients' Safety Standards

Accredited PHC units Non-accredited PHC units
Healthcare providers characteristics' (n=162) (n=63) Test of Sig.
Mean ± SD Mean ± SD

Age (years)
<25 252.86 ± 13.886 238.00 ± 0.000 t=11.688
≥40 250.96 ± 15.902 227.47 ± 17.386 P=0.000*
Gender
Male 251.07 ± 15.106 226.47 ± 20.690 F=36.694
Female 250.74 ± 14.733 228.04 ± 20.683 P=0.000
Marital Status
Single 253.60 ± 11.578 225.38 ± 20.197
Married 250.78 ± 14.891 227.60 ± 20.799 t=23.540
p=0.000
Divorced 241.25 ± 25.462 0.000 ± 0.000
Years of graduation since graduation
<5 252.79 ± 11.526 221.31 ± 20.845 t=10.660
> 40 250.32 ± 17.233 231.38 ± 19.654 p=0.000
Years of experience in the working
unit
<5 249.45 ± 15.817 224.74 ± 22.000 t=11.807
> 40 255.60 ± 12.460 252.00 ± 8.660 p=0.000

SD: Standard deviation

F=ANOVA Test t= student T test * Statistically significant at p ≤ 0.05
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