Level of knowledge and attitude among nursing students toward patient

safety and medical errors at West Bank, Palestine

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 Table of Contents

List of Tables

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 List of Figures

Figure Figure title Page

No.

Figure 3.1 Conceptual framework 34

Figure 5.1 Distribution of students’ attitudes level towards patient safety 548-49

and medical errors

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Chapter One :Introduction :

1.1. Introduction

This chapter presents background about patient safety, study problem statement,

justification of the study, significance of the study, aim, specific objectives, and

feasibility of the study. Moreover,conceptual definition of terms, operational definition

used in this study are presented.

Patient Safety:

Patient safety is the absence of preventable harm to a patient during the process of health

care and reduction of risk of unnecessary harm associated with health care to an acceptable

minimum. An acceptable minimum refers to the collective notions of given current

knowledge, resources available and the context in which care was delivered weighed

against the risk of non-treatment or other treatmenti. Nurses are the main group of

healthcare providers; they are closer to patients than other healthcare providers, and spend

the most time in providing patient care services. Nurses are well positioned to strengthen

the patient safety in health care environmentsii.

The health care organizations implement a number of approaches to help and ensure that

patients remain as satisfied as possible.Theyconciderthe quality of patient care as a

priorityby rising the awareness of quality care to the public,by increasing demand of better

care and provide competition, and by using more health care regulations and medical

avoidable errors.There are some factors that affectinghealthcarequality services,including

personal factors of the providers and the patients, and factors pertaining to the healthcare

organization, healthcare system, and the broader environmentiii.The difficulties that lead to

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problems in health care happen from medical and non-medical factors,therefore, for

improving quality of care both sides must be taken in considerationiv

An essay written by Hospital Safety Grade Organization in 2018 discussed the patient

safety as top priority,they connect between presence of good team and reduction of

mistakes, so in some hospitals there is a strong healthcare teams who reduce medical errors,

they keep checks in place to prevent mistakes,they have strong lines of communication with

each other, with patients and with families. In other hospitals they don't have good team , or

they don't have strong leadership,to insure that patient safety is top priority, the

communication between them not so good,so when one made a mistake,there isn't a good

team ready to catch mistake, that will lead to make patient experience complications of that

mistake, and recovery will be slowerv.

Patient safety should be taken into account in health education programs in undergraduate

and graduate programs, because it seems that attention that was given to patient safety and

medical errors wasn't enough. Health education programs have an important role in medical

error prevention.These programs to be successful and get its suspected outcome assessment

for nursing students'knowledge and attitudes toward patient safety and medical errors by

scientific researches should be adopted.By changing attitude,behavior can be

changedthrough appropriate educational programs and establishing a baseline data for new

teaching methods in nursing schoolsvi

1.2 Study problem

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Patient safety is the avoidance and prevention of adverse outcomes or injuries stemming

from the process of health care.For management of patient safety there should be an

operational systems and processes designed to decrease medical errors and prevent its

complications (Al - Shammari et al.,2015).

To maintain the patient safety, nursing students mustapply the protocols, policies and

procedures thatprotectpatient from medicalerrors. Medical errors could be considered as a

serious public health problem and pose a threat to patient safety. All patients are potentially

vulnerable, and medical errors are costly from a human, economic, and social viewpointvii.

Researchers observed thatthere was recognition that harm from medical errors can arise

from unintended actions.Therefore,this study will assess level of knowledge and attitude of

nursing students toward patient safety and medical errors.

Patient safety is a health care discipline that emerged with the evolving educational

programwith more attention and focus.Nursing students have an important role in patient

safety, they are the future nurses who will help to protect patients from errors and maintain

their rights. students’knowledgeand attitude should be developed throughout their study

focusing on patient safety as the first priority in providing health care.Moreover, emphasis

on interpersonal communication of students encourages collaboration and helps prevent

errors and maintain patient safetyviii.

1.3 Study Justification and Significance

There is an increasing attention toward patient safety and maintainingtotal quality health

care, but errors might be still frequent and complications appear in clinical practice.It is

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estimated that 134 million adverse events occur in hospitals in low- and middle-income

countries due to unsafe care, resulting in 2.6 million deathsix.

Internationally there were 10% of hospitalized patients experienced medical care

complications, and that at least half of complicationsare preventable.There should be

understanding of factors affect healthcare, errors and complicationsx. Interventions should

be taken to decrease medical errors must appear toand to improviingpatient

safety.Organization safety culture should be adopted to provide more safe and effective

patients care. A safety culture is linked to patient safety and its reflect a good or bad

reputation about health care servicesxi.

Being knowledgeableand experienced enough to the principles and values of patient safety

will help in providing proper healthcare and will improve confidence between patient and

health care providers. Despite the wealth of evidence published on patient safety culture in

recent years, there are limited literatures on this topic in the Arab world and Palestine in

particular. In the year 2014, it was reported that in developed countries as many as one out

of 10 patients is harmed while receiving hospital care with higher probabilities in

developing countries It was reported that the US medical errors cost the US economy

about $19.5 billion in 2008xii .

A study conducted in 2009 in Riyadh reported that organizational learning as the most

positive aspect and non-punitive response to error as the weakest aspect of patient safety

culture in public and private hospitalsxiii. In the year 2011,the Palestinian Ministry of Health

(PMoH) joined the World Health Organization’s (WHO) Patient Safety Friendly Hospital

Initiative in WHO, 2011xiv. The program required periodic assessment of safety culture at

participating hospitals. Despite these developments, there is a lack of research evidence on

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the patient safety in general and on the status of patient safety culture particularly in

hospitalsxv.

Patient safety practices are crucial toward improving overall performance and quality of

services in Palestinian healthcare organizations. To promote patient safety, nursing students

should have good knowledge and have a favorable attitude towardmanaging patient safety

and medical errors. They must learn and be prepared how to support, to have responsibility,

have communication skills to report errors, and to work as a team.

Nurses as the largest group of healthcare providers are in the best position to improve

patient safetyIt is crucial to nursing students as future nurses to have an influencing role in

developing their knowledge, skills and attitudes toward patient safety and medical erorrs.

The study results can indicate areas requiring improvements that could focus on investing

in and improving patient safety and overall performance. It should be noted that assessing

the patient safety culture is the first step in a long process for identifying areas for

improvement that health care centers can address the qulity of health service.

The recognition of the harms caused by health care should be emphasized during teaching

about patient safety in nursing education.This study will help on focusing teaching efforts

on nursingstudents knowledgetoward medical errors to enhance patient safety because

sufficient knowledge about medical errors is vital and incorrect management of medical

care can result in serious consequences such as medication errors. It is important to assess

students’ attitude regarding the patient safety and medical errors to have a baseline data to

design and implement a relevant and effective educational programs. Furthermore, the

results from this study will serve as a baseline for further studies; it will provide

information needed to improve the knowledge and attitude of nurses. The study findings

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may be used as an input for the Palestinian Ministry of Health (PMoH) and the hospital

administrators to make informed decisions regarding patient safety.

1.4 Study aim andobjectives

1.4.1Aim of the study

The study conducted to assess knowledge and attitude toward patient safetyand medical

errors among universitiesnursing students.

1.4.2 Specific objectives

In order to achieve the aim of the study, the following specific objectives are formulated:

1. To assess the level of knowledge, attitude of nursing students toward patient safety and

medical errors.

2.To determine the main factors that have an effect on knowledge and attitudes of nursing

students toward patient safety and medical errors.

3.To examine the relationship between socio-demographic factors(age ,gender ) and

knowledge and attitude of nursing students toward patient safety and medical errors.

4.To assess the association between academic year, exposure to medical error, and

knowledge and attitude of nursing students toward patient safety and medical errors.

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1.5Feasibility of the study:

1) The study was approved by the research ethical committee at Al-Quds Universty,

Plestine.

2) Approval had been obtained from Al-Quds University and Bethlehem University

administration to gain an access to nursing students.

1.6Definitions

Patient Safety:

The widely used definition of patient safety was defined and provided by the WHO in

2009, in which patient safety is defined as the absence of preventable harm to a patient

during the process of health carexvi.

Patient safety is the prevention of errors and adverse effects to patients associated with

health care (Al-Qahtaniet al., 2015).

Medical errors:

An act of omission or commission in planning or execution that contributes or could

contribute to an unintended resultsxvii.

Nursing students:

A nursing student is a student in a post-secondary educational program that leads to

certification and licensing to practice nursing. The title 'nursing student' usually applies to

students enrolled in an RN (Rigestered Nurse) or practical nurse program. A nursing

student can be enrolled in a program that leads to a diploma, an associate degree or a

Bachelor of Science in Nursing (BSN)xviii.

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Knowledge:

A ccording to Merriam-Webster, 2018, knowledge was defined as the fact or condition of

knowing something with familiarity gained through experience or associationxix. Patient

safety has been identified as a global priority area where substantial knowledge gaps exist

and where further knowledge would significantly contribute to improving patient safety and

reducing harmxx.

Attitude:

The Cambridge dictionary defined attitude as a feeling or opinion about something or

someone, or a way of behavingxxi.

It is also defined as a predisposition or a tendency to respond positively or negatively

towards a certain idea, object, person, or situation. Attitude influences an individual's

choice of action, and responses to challenges, incentives, and rewards (together called

stimuli)xxii.

1.7Operationaldefinition

A predesigned self-repot questionnaire has been formed to achieve aim and objectives of

the study. Thequestionnaire was built based on previous references and studies to

assessknowledge and attitude toward patient safety and medical errorsas follows:

Good knowledge: Student nurses, who scored above or equal to the mean score of the

knowledge questions, were considered as having high knowledge leveltoward patient safety

and medical erorrs. and, student nurses who scored below the mean score of the knowledge

questions were considered as having low knowledge level toward patient safety and

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medical errors. Favorable attitude: Student nurses who scored above or equal to the mean

score of the attitudes questions, were considered as having high attitude level toward

patient safety, andstudent nurses who scored below the mean score of attitudeslevel were

considered as having low attitude level toward patient safetyxxiii.

1.8Summary

This chapterincludes the general lines that lead to the appropriate way about starting and

writing the frame of the study. It covers the aim and objectives of the study and conceptual

and operational definitions of the variables

Chapter 2: Literature Review:

This chapter presents definitions of patient safety and medical errors, causes of medical

errors, types of medical errors, risk factors that affect medical errors and patient safety,

consequences, impact of medical errors and patient safety. Moreover, this chapter includes

review of previous studies about knowledge, attitudesof nurses and nursing students toward

patient safety and medical errors.

2.1 Introduction

The largest and main working group atany hospital of health care providers are nurses.

Nurses often provide round-the-clock care for patients.In addition to the demanding work-

hours, nurses face potential workplace stressors due to high-skill demands and the need to

work in teams with individuals from different disciplines. Thus they have an important role

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in protecting and promoting patients health by enhancing safety measures and decreasing

errors. Examination of relationship between care provided by nurses and patient safety is a

vital issuexxiv.

Patient safety and medical errors related to each other strongly, if medical errors increased

patient safety will be affected, also if patient safetymaintained this will help to decrease

medical errors. Patient safety is a top priority for healthcare institutions, therefore, nursing

programs should focus on promoting nursing students'knowledge and attitudes toward

patient safety,this will lead to provide quality health care. Nursing students attitudes and

knowledge toward patient safety will be developed mainly at nursing schools and training

institutions.Moreover, nursing education should be coordinated between inservice training

and continuing.education departments in the hospitals by supervisors and clinical directors

at in nursing schoolsto achieve competence -based education about patient safetyxxv.

To maintain the fact that patient safety and quality improvement is one of the most

priorities of health care system, asafe health system should be built through linking its

entire processes, and designingits components in order to ensure safetyfor patients from

medical errorsand associatedcomplications.Training and education are an important aspects

that support patient safety, focusing on all levels of training and education starting with

education and learning at nursing schools.Developing at these levels can give a good

support toward patient safety issuesin health care centers alsoxxvi.

2.2. Section one: patient safety and medical errors

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2.2.1 Definitions of patient safety and medical errors

Patient safety: Patient safety is the avoidance and prevention of adverse outcomes or

injuries resulting from the process of health care.For management of patient safety there

should be a well established operational systems and processes designed to decrease errors

and prevent its complications (Al - Shammariet al., 2015).

Medical error: An act of omission or commission in planning or execution that contributes

or could contribute to an unintended resultsxxvii.

2.2.2 Causes of medical errors

There aredifferent causes of errors such as: personal causes, task-related errors, situational

and organizational causes.

Personal causes:

Personal -related causes may includenurse's carelessness, tiredness, stress caused by

excessive overtime work, inadequate knowledge, insufficient experience, also financial

related problems and lack of interest in nursing job.

Task- related errors:

Task- related errors resulted mainlytowork overload that mainly affect nurses

performance.If the workload among nurses decreased, this will help in decreasing medical

errors. Workload can be reduced by increasing the personnel, proportional to the number

and condition of patientsxxviii. Routine and well-specified tasks may lead to errors but to a

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little extent compared to novel or poorly specified tasks. Tasks that have high cognitive

burden are factors affect increasing of medical errors(Dowell et al., 2009).

Situational causes:

This can includemore than one interrelated causes such as inadequate information flow,

patients related issues, communication problems,staffing patterns and workflow.Error

influenced by multiple systems factors, so to decrease errors the health care provider should

focus on how these factors arise and interrelated and lead to errorsxxix.

Organizational causes:

These cuases are related organization policies, rules,systems, processes and environment

and culture of organization.

To reduce errors, the organization should develop strategies related to health care providers.

This may include different solutions such as:educational approaches, managerial

approaches,information technology approaches, improvement of academic education

process, more accurate examination of the patients, rewarding staff with lower error rate,

increase of budget and more financial support for health services during work shifts and

work hoursxxx.

2.2.3. Types of medical errors

Medical errors can be classified as: Medication errors, laboratory errors, surgical errors,

falls, and healthcare-associated infections.

Medication errors:

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According to WHO(2016), the leading cause of injury in developed/developing countries is

medication errors:It was reported that 12% of patients were affected with error related to

prescribed drug over the year in USA,in all primary care patients.In addition to that 5% of

prescriptions had prescribing errors.InSweden the medicationerror rate was 42%, and two-

thirds of errorswere related to a failure to state the purposeof the treatment on prescriptions,

and 1% of errors resulted in an incorrect dose.In Saudi Arabia,one-fifth of primary care

prescriptions were contained errorsxxxi.

Classification of medication errors:

Medicationerrors canbe classified intothree types: Contextual, modal, and psychological

type.

-Contextual type:Related to errors in specific time, place, medicines, and people

involvedxxxii.

-Model errors:Related to ways in which errors during medication preparation and

administration for example: omission, repetition, or substitution.

- Psychological type:Focus on events rather than merely describing them.It looks at

medication errors based on psychological approachxxxiii.

Laboratory errors:

The process of laboratory testing and its devices are complexand not safe enough. The

trend that appears to found that laboratory errors is quality control methods and quality

assessment programs focus on analytical aspects of testing.Severalstudies considered that

quality can't be ensured only from analytical testing.Mistakes may occurred before (pre),

through (Intra) and after (post) analytical the test has been performed. A study conducted

by Plebani(2006)reveald that most of errors were occur pre analytical (46-68.2% of total
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errors), while 18.5-47% of total errors were occured in the post-analytical phase. Through

process of testing,laboratory errors appeared in many cases,these errors could occur due to

poor communication, action taken by others as physicians and nurses involved in the

testing process, or improper designed processes. Sometimes laboratory information are

partially utilized, and this can lead to errors.The modern approach concentrate on define

laboratory errors related to patients' needs and satisfaction, this might help to decrease

laboratory errorsxxxiv.

Other study conducted by Miligy in 2015 revealed that the total number of encountered

errors from the data obtained out of 1600 testing procedure was14 tests (0.87% of total

testing procedures). Most of the encountered errors lay in the pre- and post-analytic phases

of testing cycle representing 35.7% and 50%, respectively, of total errors. While the

number of test errors encountered in the analytic phase represented 14.3% of total errors.

About 86% of total errors were of non-significant implication on patients’ health being

detected before test reports have been submitted to the patients. On the other hand, the

number of test errors that have been already submitted to patients and reach the physician

represented 14.3% of total errors. It was reported that about 7% of the errors could have an

impact on patient diagnosisxxxv.

Surgical errors:

There are many surgical errors do not appear, or were hidden, it is called surgical events,

and cost the health system in world money, this cost could have been avoided if such errors

have been reported.

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A modeling study estimated that 234 million operations are carried out every year across

the world. This translates to one operation for every 25 people and is more than the number

of children born worldwide each yearxxxvi. Despite the positive impact on the provision of

surgical services, it can have an impact population’s health, surgery itself carries risk.

Current estimates of morbidity and mortality following surgery indicate that over 7 million

people worldwide will suffer complications following surgery, and about one million of

these people will die as a result. Around half of these complications are potentially

preventable.The study revealed that using the checklist to improve the safety of surgery will

save many thousands of lives each year.

Surgical never events include operating on the wrong part of the body, performing the

wrong procedure, leaving instruments or swabs in side the body or having wrong prosthesis

or medical device implementedxxxvii.

Surgical never events are costly to the health care system and are associated with serious

harm to patients. Patient and provider characteristics may help to guide prevention

strategies.A study conducted by Mehtsun and colleagues in the United States in 2012

identified a total of 9744 paid malpractice settlement and judgments for surgical never

events occurring between 1990 and 2010 to describe the number and magnitude of paid

malpractice claims for surgical never events, as well as associated patient and provider

characteristics. The study reported that malpractice payments for surgical never events

totaled $1.3 billion. Mortality occurred in 6.6% of patients, permanent injury in about 33%,

and temporary injury in about 59%. The researchers estimated that about 4100 surgical

never event claims occur each year U S. Increased payments were associated with severe
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patient outcomes and claims involving a physician with multiple malpractice reports. In

addition to that of physicians named in a surgical never event claim, 12.4% were later

named in at least one future surgical never event claimxxxviii.

Falls:

Patients defined medical errors to include not only clinical mistakes but also falls related to

communication problems, and patient responsiveness. Falls are main concern of patient

safety as a type of medical errors. Patients need to feel safe when they receive their

healthcare in their rooms or in any other places. Health organizations should have policies

that protect patients from fall, especially unconscious, disoriented or simioriented patients.

Falls may result from negligence from health care providers or decrease in their attention

for patients.Fall prevention involves managing a patient's underlying fall risk factors and

optimizing the hospital's physical design and environment (Ganz et al.,2013).

Fall prevention involves managing a patient‘s underlying fall risk factors such as problems

with walking and transfers, medication side effects, confusion, toileting needs and

optimizing the hospital‘s physical design and environment (Ganz et al.,2013). A study

conducted in the United States in 2013reported that between 700000 and 1000000 people in

the United States fall in the hospital each year. A fall may result in fractures, lacerations, or

internal bleeding, leading to increased health care utilization. The study reported that about

one-third of falls could be prevented. (Ganz et al.,2013).

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An errors that result from falls can be avoided by improving in communication that can be

achieved byfocusing on technology as a tool for reduction of falls, example, side rails on

beds. Health care providers should use technology in proper way to protect patients. If a

patient has high risk of fall,precautions must beconsidered to prevent harm. Patients beds

have the most elements to protect patients( bed rails, bed height, bed brake, and bed alarm).

Also falls can occur if patient are dizzy or has general weakness.Health care provider

should stay with patientsduring walking or in doing theiractivity daily livings (Medi sign

displays, 2017).

Alsousingtechnology have such role to protect patients, like using wheelchair electronic

whiteboards, door displays, nurse station whiteboards, and mobile devices. These examples

can show the importance of technology in prevent falls and maintain patients' safety. Health

providers should be alert for unsafe conditionsto decrease falls and increase patient safety

(Medi sign displays,2017).

Health care associated infections(HCAI):

Infections can be associated with the devices used in medical procedures, such as catheters

or ventilators; there are many types of invasive devices and procedures to treat patients and

to help them recover(Centers for Disease Control and Preventionxxxix.

Types of Healthcare-associated Infections(HCAI):

Healthcare-associated infections (HCAI) are infections that patients develop during the

course of receiving health care. They can happen due to treatment in hospitals and other

healthcare facilities including outpatient surgery centers, dialysis centers, long-term care

facilities such as nursing homes, rehabilitation centers, and community clinics. They can

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 also occur during the course of treatment at home. HCAI can be caused by a wide variety of

common and unusual bacteria, fungi, and virusesxl.

HCAIinclude central line-associated bloodstream infections, catheter-associated urinary

tract infections, and ventilator-associated pneumonia. Infections may also occur at surgery

sites, known as surgical site infections. It is identified that millions of patients are affected

by HCAIeach year; this can lead to increase mortality rate in addition to financial

losses.There are7 from 100 hospitalized patients will acquire one of HCAI at any time in

developed countries, in copmparison to 10 from 100 hospitalized patientsin the developing

countries.In Europe,there are 5 million HCAI happen in hospitalsper year,andthere are 1.5

million are harmed from HCAI per yearin USAxli.

2.2.4 Risk factors related to medication errors

 A medication error is defined as "any preventable event that may cause or lead to

inappropriate medication use or patient harm while the medication is in the control of the

healthcare professional, patient, or consumer"(Medical Devices Regulatory Consulting,

2020).

 A study that conducted by Schwappach in 2010, reported that many risk factors related to

medical errors included:age, gender, income,and educational level. The study results

showedthat the higher age was inversely related to some types of reported errors, except

medication errors. Female gender was associated with medication error, but not the subset

of laboratory errors. Low income was associated with all types of reported errors except

laboratory errorsxlii.

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 The Food and Drug Administration (FDA) states that a medication error occurs upon

administering a patient medication and as a result, patients are harmed in some way.

Medication errors can be preventable, had more attention been provided by healthcare

provider, the patient, caregiver and the pharmacist. Medication errors can occur throughout

the medication-use system such as when prescribing a drug, entering information about the

drug, being prepared or dispensed, or when the drug is given to or taken by a patient. The

FDA receives more than 100,000 U.S reports each year associated with a suspected

medication error. FDA reviews the reports and classifies them to determine the cause and

type of error. Serious harmful results of a medication error may include: death, life

threatening situation, hospitalization, disability and birth defect(Medical Devices

Regulatory Consulting 2020).

Nurses must make a professional decision and apply their safety skills in administering any

medication to the patientxliii. A study conducted by McMullan and colleagues in 2010

reported that nurses might be had poor numeracy skills, as the results of the study showed

that both nursing students (about 56%) and registered nurses (about 46%) failed the

respective numeracy and drug calculation tests (McMullan et al., 2010). Nurses were

significantly more skilled than students in performing basic numerical calculations and

calculations for solids, oral liquids and injections, and nursing students and registered

nurses were significantly skilled in performing calculations for solids, liquid oral and

injections, rather than calculations for drug percentages, and drip and infusion rates. Nurses

are the largest occupational group in the health care facilities, they have an important role

in enhancing quality and patient safety by using their safety skills to identify safety

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problems and implement solutions to improve patients’ care, treatment and health care

environmentxliv.

2.2.5 Consequences, Impact of patient safety and medical errors

According to WHO in 2012, health is an industry, that has many errors to make it one of

the most unsafe industries.Studies showed that 10% of hospitalized patients suffer from

complications related to errors, the incidence of adverse events in developing countries was

higher than 10%. Some sorts of adverse events included: missed and delayed diagnoses,

mistakes during treatment, medication mistakes, delayed reporting of results,

miscommunications during transfers and transitions in care, inadequate postoperative care,

and mistaken identity. Many factors were related to increase adverse events in developing

countries included: poor state of infrastructure and equipment, unreliable supply and

quality of drugs, shortcomings in infection control, medical wastes management, poor

performance of personnel, low motivation or insufficient skills and severe under-financing

of the health services. To understand these factors reporting and analysis of errors could be

used and be essential in order to develop changes that will prevent future errorsxlv.

There are many consequences of medical errors on health care providers and patients. For

health care providers, almost cause personal distressasthey may experience feelings of

guilt, disappointment, and fear and sense of inadequacy of varying degree.These

consequences are vital issue that might lead to more errors if the person cannot

overcomethese feelings. Also it might have an influence on their behaviors andwork. Some

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health care providers mis report or prefer not to report their errors, thus make them more

vulnerable to stress and make more errors than those who will report their mistakes. xlviThe

consequences were vary from no harm or little harm to being murderer to patientsxlvii.

A study conducted by Schwappach in 2010 aimed to identify the common risk factors for

patientreported medical errors across 11 countries (total sample 19738 adults). Data from

the Commonwealth Fund’s 2010 international survey of the General Public’s Views of

their health care system’s performance. The representative population samples of utilization

of health care, coordination of care problems and reported errors were assessed. The

resultsshowed thaterror was reported by 11.2% of patients and with differences between

countries ranged from 5.4 to17%. Poor coordination of care was reported by 27.3%. The

risk of patientreported error was determined mainly by health care utilization: Emergency

care (OR=1.7, P< 0.001), hospitalization (OR=1.6, P< 0.001) and the number of providers

involved (OR three doctors=2.0, P< 0.001) are important predictors. It revealed that poor

care coordination was the single most important risk factor for reporting errors (OR=3.9, P

< 0.001). The study concluded that safety remains a global challenge affecting many

patients throughout the world. A large variability existed in the frequency of

patientreported error across countries. Furthermore, to learn from others’ errors is essential

within countries and may also prove a promising international strategyxlviii.

2.2.6knowledge and Attitude of nursing students toward patient safety

and medical errors

Education programs should be increasing its focus on patient safety and medical errors,

these programs involved all levels of health care disciplines.

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The WHO (2009) stated that further research is needed to reduce patient harm. Thus, one of

the main structural challenges for health care systems is the inadequacy in numbers and

allocation of qualified health professionals, and their insufficient knowledge about patient

safety and safe practice. Health care professionals need to maintain their competency which

is in-turn needed to ensure patient safety and provide safe care. Researchers suggest that

providing nurses with positive attitudes, adequate skills and knowledge regarding patient

safety, is likely to improve safe practices, to strengthen patient care, and also to decrease

morbidity and mortality ratesxlix.

Nursing students' attitudes and knowledge related to patient safety can be affected by multi

factors such as lack of educational programs coverage about patient safety, lack of training

programs about medical errors and patient safety,age, gender, communication and

professional skills,and educational levelsl.

Patient safety researches should provide insights on how well nursing students prepared to

taking care of patient safely. The focus should be on such factors that affect student

perception about patient safety,and their understandingabout patient safety.Nursing

education program designers should use theoretical concepts about patient safety and

developstrategies to increase presence of patient safety and medical errors subjects in

educational programsli Patient safety is a major subject in education at national and

international levels in order to maintain quality improvement (Olafet al., 2014).Moreover,

there is a need to create a culture of reporting to assist in medical errors reporting and this is

an important aspect for training of nursing student nurseslii. Nursing students should be

trained on the skills to analyze and report errors.

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2.3Section Two: Previous studies on knowledge and attitudes of nursing

students toward patient safety and medical errors

2.3.1International studies

A cross-sectional study was conducted by Safarpour and collegues in 2017 among 140

nursing students in Ilam, Iran. The study aimed to assess attitudes, skills, knowledge and

barriers related to reporting medical errors by nursing students. Data were analyzed with t-

test, regression and correlation coefficients and descriptive statistical methods. The study

results showed that nursing students had a positive attitude with respect to the reporting of

medical errors (p = 0.01). Thethe study showed that low students’ knowledge ofmedical

errors and reporting them. There were significant differences in all groups and subgroups of

knowledge, attitude, and skills (except creating of safety culture subgroup) between the two

group’s students. Moreover, the main reason for not reporting was the lack of knowledge

and fear of punishment. Authors concluded that in order to improve patient safety and the

process of reporting medical errors nursing students’ participation in the process of

reporting error is essential. Moreover, there is a need for adopting effective contemporary

educational modelsto enhance knowledge and attitudes of nursing studentsliii.

A cross-sectional survey was conducted by DomenicoFlottaand collegues in 2012 aimed to

investigate physicians' knowledge about evidence-based patient safety practices, and their

attitudes on preventing and managing medical errors,further to explore physicians' behavior

when facing medical errors. The study was conducted in 40 hospitals involved 696

responded physicians out of 1200participants . Logistic regression was used in analysis,

‘alpha’ level to judge the importance of variables, andP- value in different levels,

theresearchers calculated Odd Ratios (ORs) and 95% confidence intervals (CIs) of the

26
adjusted ORs to estimate the association between the characteristics and outcomes.The

results of the study showed inconsistent knowledge of physicians about evidence-based

safety practices. There were more than 90% of physicians believed that the importance of

counting surgical items in any invasive surgery is an evidence of patient safety. In general

there are positive attitudes about patient safety showed by participants but 44.5%agreed the

disclosure of errors to the patients and 44% were uncertain about that. The study showed

that 7.6% of physicians was never involved in medical errors. The item that take the highest

rate as the main cause of errors is overwork, stress or fatigue of health professionalsliv.

A descriptive exploratory study was conducted by Elorrioand collegues in 2016aimed to

validate the modified attitudes for patient safety questionnaire to measure knowledge,

beliefs, and attitudes of medical students at CEMIC University Institute. It was conducted

among 100 participants from 4th and 5th year medical students. For analyzing the data,the

reserchersused a Cronbach's alpha for reliability, Likert scale, and alpha value. The

collected data was evaluated using STATA, version 13.0. The study reported that 57% of

participants believe they understand concepts about patient safety, 53% of them depend on

their medical training to understand concepts of patient safety. 59% shows that human error

is inevitable and 98% of them believe if they were real professionals they will don’t make

mistakes. Sixty four percent convince that knowledge about patient safety is only acquired

from clinical experiencelv.

A descriptive study was conducted by Korhanand collegues in 2016 aimed to determine the

attitudes of nurses toward medical errors and related factors. Atotal of 151 nurses working

in an education and research hospitals were participated in the study. For data analysis:

“SPSS forWindows 22.0” software package program was used and the significance level in
27
the study was determined as p<0.05. The results of the study showed that there were: 86.8

% of participants were women, 26.5% has experience from 6-10years, 59.6% of

participants work in internal departments, 80% of them working in the clinics , and about

69% were work more than 40 hours in a week.62.3% of participants received training

related to medical error applications, 13.9%of nurses reportedthat they faced a medical

error application, and 4.6% of them faced an error of “wrong dose of medication”lvi.

A descriptive cross-sectional study was conducted by Cauduroaand collegues in2015

aimedto verify the understanding of graduate students on patient safety. The study

compromised 638 students at the Health sciences center of the Federal University of Santa

Maria, Brazil. The Likert scale was used in the questionnaire. The database was organized

in an Excelspreadsheet and analyzed in the Predictive Analytics Software program, using

descriptive statistics.

The study showed that most of students reported that they don’t take formal training about

patient safety. The study reported that the main aspects of safety culture are: importance of

systemic error analysis, the concern with the work environment and appreciation of

teamwork. Some attitudes of students show uncertainty to patient safety in acting with

patients. Also most of participants has positive perception toward patient safety.

Furthermore, educational programs need formalization of the subject at its different

levels(Cauduroaet al., 2015).

Across- sectional study was conducted by Nabilouand collegues in2012 aimedto assess

students’ perceptions of patient safety, and their knowledge and attitudes toward patient

safety education. A total of134 nursing, medical and midwife students in Urmia University,

Iran, participated in thestudy. SPSS (version 16.0)was used for data entry and analysis,Chi-

square test, Spearman correlation coefficient, F and LSD testsused for data analysis.
28
It was reported thatstudents are believed that medical errors are barrier between current

care and best care.Students level of knowledge was little about factors related to medical

errors.The study recommended thatchanging in educational programs and training must be

done to decrease the gap in knowledge and concern about patient safety. The study

recommended that therere is a need to formulate a new health policies to improve patient

safety and decrease errors (Nabilouet al., 2012).

A cross-sectional and interventional study was conducted by Aghakouchakzadeand

colleguesin 2015aimed to assess the knowledge, attitude and practice of medical students

towards medical errors and adverse drug reactions reporting. It is included 40 students of 4th

year level. For data analysis, Content validity ratio (CVR) and Content validity index (CVI)

were used to determine validity, Cronbach’s alpha was used for assessing the internal

consistency reliability.

It was reported that there is no significant differences appear on demographic

characteristics of participants.Eight percent of students reported general knowledge about

medical errors ,50% reported that medication errors are inevitable, 20% of them were

knowing about five rules of prescription.Participant reported that they have well knowledge

and attitude toward adverse drug events reporting,but they has poor practice.More over, the

results showed that 55% of participants know that they have responsibility toward adverse

drug events reporting, and 5% reported that they knew about method of reporting.The study

concluded that there must bean educational and training programs about medication errors

and adverse drug events tailored to studentslvii.

Another study was conducted by Anderson and Abrahamson in 2017on 25 hospitals that

had submitted 17,000 reports in PennsylvaniaThe studyaimed to describes the results of an

investigation of the effectiveness of the implementation of the MEDMARX Medication

29
Error Reporting. . For data analysis, Latent growth curve analysis was employed to analyze

whether the changes in error reporting and corrective actions by the hospitals were

statistically significant. This methodology estimates a regression curve for each hospital’s

data and produces a summary curve based on data from all of the hospitals in the sample.

The study findings were:Implementation of computerized physician order entry(CPOE)

only will make no serious difference on the number of medical errors. Consolidation of

decision making to the CPOE system, the model showed that 20% will be decreased on the

number of medical errors. Participation of the clinical pharmacists in the physician rounds

shows reduction in the medical errors numbers. The model predict a 70% as a huge

decrease in number of medical errors that could happened when the hospital commits to

root-cause-analysis and system changes to prevent future errorslviii.

A cross-sectional study wasconducted by Lun Lo and collegues in 2018 aimed to examine

medical students’ perceptions towards medical errors and the policy of the hospital within

the internship curriculum, and explored how aspects of personality traits of medical

students relate to their attitude toward medical errors. The study included medical students

(in their 5th, 6th and 7th years level), from three medical schools in Taiwan. For data

analysis,theesearchersused descriptive statistics, including Mean, Standard deviation

(SD),Pearson correlation coefficient, and multiple regression.

The findings of this included213 respondents in analysis with response rate 56.9%.The

results showed that 70% of interns believe that medical mistakes can be avoided, and more

than half of the respondents confirmed that education and training will reduce medical

errors.The study concluded that the greatest influence on medical students’ attitude towards

medical errors is agreeableness and conscientiousnesslix.

30
2.3.2National studies

Across-sectional study was conducted by Almaramhyand colleguesin2010 aimed to assess

knowledge and attitude of undergraduate medical students towards patient safety concepts,

and to detect variation by the mode of learning. Participants in study were 150medical

students graduated from two national medical schools.

The study revealed that 52.7% of participants rated their general knowledge about patient

safety with a good level. 60.7% of participants agreed about the importance of patient

safety, 76.0% of participants agreed that if one of peers make unintentional error they will

support him,44.7% agreed that there are important rolefor patients in error prevention,and

47.3% agreed to error disclosure to the patient(Almaramhy et al., 2010).

Across-sectional study conducted by Al-Khaldi in 2011 to assess the attitude of physicians

at primary health-care centers in Aseer region toward patient safety. The study was

conducted among working primary health-care physicians included 228 doctors.For data

collection,the researcher used a self-administered questionnaire consisting of three parts

included: socio-demographics, academic and work profile of the participants. And for data

analysis,the researcher used SPSS version 15, Likert scale, Chi-square and ANOVA were

used, P values were considered significant if <0.05.

The study found that one-third of participant took a course on patient safety, 52% of them

were defined medical error correctly. It showed that physicians in Aseer region reported

that they have positive attitude toward patient safety, also most of the participants reported

that they need courses and training about patient safety and medical errors,and the

undergraduate educational programs need development on issues towaredpatient safetylx.

31
A cross-sectional study conducted by Bariandcollegues in2016 aimed to determine the

causes of medical errors, the emotional and behavioral response of medical residents to

medical errors. A total of 130 postgraduate residents were included. SPSS, version 20

software was used for data analysis. Theresearchers calculatedthe mean and standard

deviations for continuous variables, frequencies and percentagesand Chi-square test for

categorical variablesn were used. A p value of <0.05 was considered statistically

significant.

It was found that, 98.5%of participants explained some form of errors that happened with

them. 19% of these errors were serious errors, 48%were minor, 19%were near misses, 2%

never encountered an error and 12% of participants did not mention the type of error but

mentioned its causes and consequences. 57%of participants disclosed medical errors to

their senior physician, 11% of participants' disclosure error to patient’s family. Causes of

errors causefatigue due to long duty hours 65%, inadequate experience 52%, inadequate

supervision 48% and complex case 45%. The study also showed that medical errors had

significant impact on resident’s behavior: 93% of residents became more careful, 86% of

them increased advice seeking from seniors and 86% of them started paying more attention

to detailslxi.

A study was conducted by Elmontsriand collegues in 2016 aimed to explore the status of

patient safety culture in Arab countries based on the findings of the Hospital survey on

patient safety culture. It was conducted using 18 previous studies from 2005-2015.The

findings were: Healthcare providers in Arab countries still show that culture of blame still

present, so this prevents them from reporting errors. They found that the team work within

departments of hospital better than and support patient safety more than team work across

departments of hospitals.All previous studies shown that education in hospitals are

32
continuous and satisfactory with rate 73.2%.Also they shown that communication in these

hospitals still need improvement. Patient safety still need support and it’s a strategy for

developing patient safety, and this requires participation from all stakeholders in health

care (Elmontsriet al., 2016).

2.3.4Local

Across-sectional study was conducted by Elsousand collegues between 2013-2014 aimed to

measure and establish a baseline assessment of the patient safety culture in the Palestinian

hospitals. The study incuded339 nurses and physicians in four public general hospitals in

the Gaza Strip, Palestine. For data analysis,theresearchers used SPSS,version 20 software

and p- value less than 0.05 to be considered statistically significant. Cronbach alpha was

used to measure internal consistency.

Findings of the study were: The positive attitude toward patient safety were related

to34.5% for teamwork climate, 28.4% for safety climate, 40.7% for stress recognition,

48.8% for job satisfaction, 11.3% for working conditions and 42.8% for perception of

management. The study concludedthat healthcare providers who have positive attitudes to

patient safety have better collaboration with co-workers than those without positive

attitudes (Elsouset al.,2016).

A retrospective, exploratory study was conducted by Najjarand collegues in2015 aimed to

explore the relationships between patient safety culture and adverse event rates at unit

levels in Palestinian hospitals, and provide insight on initiatives to improve patient

safety.The study used the IHI Global Trigger Tool for measuring adverse events and the

hospital survey on patient safety culture.

33
The results of the study were: at department level there was a relationship between rate of

adverse events and safety cultures, and if the department has positive safety culture adverse

events will decrease, but if the department has negative safety culture the adverse events

will increaselxii.

34
 Chapter three :Framework

3.1Introduction

Framework:

The conceptual framework link each concepts together, to explain the relationships between

them to describe phenomena.

According to Gubaand Lincoln (1994) each concept in conceptual framework has

ontological or epistemological role that helping in explain an issue, also there are

methodological assumptions appear and linked with concepts roles to make the nature of

reality or real action(Gubaand Lincoln, 1994).

Conceptual framework provides critical, historical perspective of the topic, and shows gaps

that may appear in research, it explains the entire relationships in process, the events

behaviors and how it react with each other,and define data that used to answer questions of

research, Bordagein2009 mentioned that "Conceptual frameworks represent ways of

thinking about a problem or a study, or ways of representing how complex things

work"(Bordage,2009).

3.2Dependent variables

Knowledge and attitude of nursing students towards patient safety and medical errors.

3.3Independent variables

35
 Socio-demographic factors:age, gender, marital status,academic year ,training, exposure to

medical errors.

Independent Variables: Dependent Variables:

 Socio-demographic -Level of Knowledge of
factors(Age , Gender , nursing students toward
Marital Status) patient safety and medical
 Academic Year errors
 Training -Level of Attitudes of nursing
students toward patient safety
 Exposure to medical error
and medical errors

Figure 3.1: The relationship between socio-demographic variables,academic

year,training,exposure to medical errors and level of knowledge and attitude of nursing

students toward patient safety and medical errors.

Age:Is the interval of time between the day, month and year of birth and the day and year

of occurrence of the eventlxiii.

Gender: The socially constructed characteristics of women and men - such as norms, roles

and relationships of and between groups of women and men. It varies from society to

society and can be changed. In this study it is two categories :male and femalelxiv.

Academic year:

That period of time necessary to complete an actual course of study during a school year,

(The Free Dictionary, 2003).In this study its third and fourth year nursing students.
36
Training:

Training concerning patient safety and medical errors.

College:

A college is an institution where students study after they have left schoollxv.

-Dependent variable: Level of knowledge and attitude among nursing students toward

patient safety and medical errors.

I-independent variables:Socio-demographicsincluded: age,gender,marital status,academic

year,training services, and exposure to medical errors.

3.4. Summary

- This chapter presented the conceptual framework which was developed based on literature

review, it consisted of two major concepts:

37
 Chapter four :Methdology

4.1.Introduction

This study is conducted to assess the level of knowledge and attitude of nursing students

towardpatient safety and medical errors. To achieve this purpose, a quantitative design was

utilized. This chapter includes: Study design, study population and sample size, instruments

of the study, data collection process, statistical analysis, sample frame, and ethical

considerations.

4.2. Study design:

A quantitative descriptive cross- sectional design was selected for the current study. It

involves the collection of data at one point in time were and analyzed at one time. It is

appropriate for describing the status of the phenomena (Knowledge and Attitude) for

describing the relationships among phenomena at fixed point in time. The purpose of the of

this design is to describe and document aspects of the situation. Thisdesign was used to

identify the knowledge and attitude ofPalestinian nursing student. The advantages of this

design is relatively inexpensive,and could be conducted quickly.The disadvantages of this

type of design that it cannot determine causation between exposure and outcome. The

design is quantitative. While it considered descriptive, since the information is collected

without changing the environment in where the study was conducted (Aliaga and

Gunderson,2005).

38
4.3. Study population

Study population

The study population included Palestinian nursing students from Bethlehem and Al-Quds

university.

Sample and Sampling technique

Aconvient sampling methods was used to recruit the participants. The total population is

334 nurses (Table 4.1). The sample of this study is third and fourth year nursing students

who are studying at Al-Quds and Bethlehem universities in the academic year 2019-2020.

Table (4.1): Population and sample of the Study

Third year Fourth year Total number

University

Bethlehem 60 38 98

Al-Quds 138 98 236

Total 198 136 334

4.4 Pilot Study

The study questionnaire waspilotedat2019, and minormodifications were implemented. The

questionnaire was piloted prior to formal data collection by randomly selecting 10 nursing

39
students from Al-Quds University. After piloting, somequestions were amended and

rephrased to improve clarity.Also to test the feasibility of conducting the study and

suitability of the instrument and to improve its validity and reliability. According to the

results of the pilot study, the final format of the questionnaire was finalized with a minimal

modifications.

4.5. Study tool (research instruments)

The study questionnaire assesses the level of knowledge and attitude among nursing

students related to patient safety and medical errors. It was adopted and developed in

accordance to the tools and validated questionnaires used in the previous studies, and

modified by the researcher as appropriate to suit the study purpose. The tools of the

following studies were used to develop the questionnaire:

1- Knowledge, Attitude, and practice towards medical errors and adverse drug reaction

reporting among Medical students.

2.- Attitude of primary care physicians toward patient safety in Aseer region, Saudi Arabia.

3- Knowledge and attitude towardspatient safety among a group of undergraduate medical

students in Saudi Arabia.

4-Patient safety awareness among postgraduate students and nurses in a tertiary health care

facility.

5-Medical errors; causes, consequences, emotional response and resulting behavioral

change.

6- Patient safety in the understanding of health care students.

40
7-A cross-sectional study to assess the patient safety culture in the Palestinian hospitals: a

baseline assessment for quality improvement.

8-Investigating the causes of medication errors and strategies for prevention fromnurses

and nursing student viewpoint.

9-The relationship between patient safety culture and adverse events: a study in Palestinian

hospitals.

The questionnaires were administered to collect different types of information (appendix 1).

The questionnaires included the following:

Section one:Socio-demographic data such as gender, age, marital status,acadimic year ,

training and zexposure to patient safety and medical errors

Section two:Self-reported questions about the level of knowledge and attitude among

nursing students about patient safety and medical errors. This part uses a five pointLikert

scale which is used to allow the participants to express how much they agree or disagree

with a particular statement toward patient safety and medical errors (Respondents were

asked to select the appropriate point on a 5-point Likert scale, which ranged from 1

(strongly disagree) to 5 (strongly agree).

4.6. Data collection

After getting permission from the administrators at Bethlehem and Al-Quds universitiesand

nursing departments who were informed and approached about the study to facilitate

meetings with the nursing students after their lecture time. The questionnaires were

distributed at the end of the lecturesafter explainingthe purpose and objectives of the study

41
and assureing students that privacy and confidentiality will be maintained and there is no

need to put their names on the questionnaire. at their class rooms. The students were asked

to complete a paper copy of the questionnaire distributed in the last 15 minutes of a lecture

period and to return it to the researcher, who was present. It was emphasized that

completion of the questionnaire was voluntary. Students were instructed to put the

questionnaire in a closed envelope onthe allocated desk in the class rooms.

4.7. Reliability of the study tool

Stability means estimating and assessing the reliability and stability of measures, the

internal consistency of the measuring instrument, and the mutual reliability of scores of

instruments (Kimberlinand Winterstein, 2008). Stability or reliability is the degree of

measures that are error free and therefore yield consistent results (i.e. consistency of

measurement procedure. If the measuring instrument or procedure consistently assigns the

same degree to individuals or objects with equal values, the instrument is considered

reliable (KimberlinandWinterstein, 2008). Reliability implies consistency, or repeatability,

of test scores, i.e. the degree to which one can expect a relative degree of deviation from

states on the same test instrument (Carole et al., 2008).

In this study, reliabilitytest (Cronbach'sAlpha) was calculated, reliabilityhas been calculated

using method of inte0rnal consistency, it was calculated for questionnaire as a whole, and

for all its items and for knowledge and attitude parts, as shown in the following table (4.2):

42
Table (4.2) The reliabilityof the study instruments according to the Cronbach's Alpha

test

No. of
Cronbach's Alpha
items

Reliability of overall scale

(knowledge and attitude scale 31 0.884

Reliability of knowledge 17
0.738

Reliability of attitudes scale 14 0.888

The reliability of study tool was 0.88, and this means that study tool can measure what was

designed to measure. Also each attitudes and knowledge scale was reliable with a

Cronbach'salphaof more than 0.70 which means that they measure what were designed to

measure and stable in getting same results in different occasions.

4.8. Validity of the study tool

The validity of the research tool is defined as the extent to which the tool is measured to

what it aims to measurelxvi.

The questionnaire was sent to five experts in patient safety and medical errors(Appendix 3),

they reviewed it and had some modifications.The questionnaire was modified according to

their recommendations.

43
4.9. Permission andethical considerations

School of public health ethical committee approvedthe study.The permission to gain access

to student nurses was facilitated and reviewed by nusingadministraters in Al-Quds and

Bethlehem universitiesin both colleges.The participants were provided with information

about the purposes of the study and were informed that the collected data were strictly

confidential and would only be used for research purposes. Additionally, they were

informed that their participation was voluntary, that they could refuse to answer any item,

and that there would be no adverse consequences for refusing to participate. Confidentiality

of the data was assured by collection of the completed questionnaires in sealed envelopes.

Only the researchers then had access to the data. The questionnaires did not include any

personal identifying information and the individual's responses or results could not be

linked to his/her identity. Coding and aggregate reporting were used to eliminate

respondent identification and ensure anonymity.

4.10. Statistical analysis

The collected data were entered into a computer for analysis.All of the data was analyzed

using SPSS (Statistical package for social sciences) (version 22.0; SPSS Inc., Chicago,

Illinois, USA). A p value of <.05 was considered to be statistically significant. The

researcher analyzed the data with the help and support of a statistician. Descriptive statistics

like means, Standard Deviations (SDs) were used for continuous variables, while

categorical variables were expressed as frequency. Moreover, inferential statistics

44
likePearsons' chi-square, T-test and One Way Analysis of Variance (ANOVA) test,Tukey

test and Cronbach's AlphaStability Equation were used for data analysis.

4.11. Scale correction

To calculate reference arithmetic averages, the length of interval was calculated, which is a

division of 5-1/5, it equals (0.80), so the results were interpreted as follows:

Table (4.3): Basic correction keys

Mean Level

1.00 – 1.80 Very low

1.81– 2.60 Low

2.61– 3.40 Medium

3.41 – 4.20 High

4.21 – 5.00 Very high

For the purpose of facilitating analysis and presentation of results, the standard of mean

adopted as follows (based on 3 intervals: 5-1/3=1.33 (Interval length)).

Table (4.4): Modified correction keys

Mean Level

1.00 – 2.33 Low

2.34 – 3.67 Medium

High

These modified corrective keys were used in all statistical analysis tests in this study.
45
4.12 Summary

This chapter provided an overview of the methodology which was used in this study,

describing the study design, the targeted population, data sampling, data collection and

analysis processing using SPSS IBM version.23 software.

46
Chapter five :Study results:

5.1. Introduction

This chapter presents the study results in relation to study objectives, this

includes:characteristics of respondents, results related to level of knowledge of nursing

students toward patient safety and medical errors, results related to the level of attitudes of

nursing students toward patient safety and medical errors, the relationship between socio-

demographic characteristics (age,gender, marital status, academic year,training, and

exposure to medical errors) and knowledge and attitudes of nursing students towardpatient

safety and medical errors,the association between academic year, exposure to medical error,

and knowledge and attitudes of nursing students towardpatient safety and medical errors,

andthe association between the nursing study circulumand knowledge and attitudes of

nursing students toward patient safety and medical errors.

5.2. Response rate

The response rate in this study was 67.7%, Table 5.1 showsthe distribution of the study

respondents according to academic institutions and study year level in nursing.

Table (5.1): Response rate

University Thirdyear level Fourthyear level Total of participants Response rate

Bethlehem 23 65 88 89.7%

Al-Quds 81 57 138 58.5%

Total
104 122 226 67.6%

47
5.3: Characteristics of respondents

Three hundred and thirty four questioners were distributed at both Bethlehem and Al-Quds

Universities, the researcher itended to includ all study population whilethe number of

returned questionnaire were 226 with a response rate 67.7%.The sample comprised 173

(76.5%) females and 53 (23.5%) males. According to age, about 40% of participants were

between 20-21years old and the majority 53.1% were between 22-23years old, and 8% of

them were more than 23years old. According to academic year, 46% of participants were

thirdyear level and 54% were fourthyear level in nursing. According to marital status,about

81% of participants were single, 12% were married and 7%were engaged. 138 (61%) of

participants study at Al-Quds University and 88 (39%)study at Bethlehem University.

Table (5.2) shows socio- demographic characteristics of the study sample. It was found that

76.5% of participants are females, and 53.1% of them aged 22-23years with mean age of

21.04 years,54.0% are fourth academic year level in nursing, and 81% of them were single.

Table 5.2: Socio-demographic characteristics

Variable Groups No. %

Female 173 76.5

Gender Male 23.5

53

20-21 88 38.9

22-23 120 53.1

Age (year)
>23 18 8.0

Mean (Standard Deviation 21.04 (1.39)

48
 Academic year Thirdyear 104 46.0

Fourthyear 122 54.0

Marital status Single 183 81

Married 27 11.9

Engaged 7.1
16

Total 100
226

5.4. Level of knowledge of nursing students toward patient safety and medical errors:

The researcher calculated sum of scores ofstudents.correct answeresbased on the following

scale:

Researcher used scale items of (yes=1, no=0), student who answered 18questions correctly

had the highestmeanscore, some questions have been answered by no (0 score). the highest

score is (18) and the lowest score is zero (0).

Table (5.3): level of participants’knowledgetowardpatient safety and medical errors.

Frequenc Percent

Knowledge 0-5 points (Low level) 63 27.9

6-11 points (Medium 161 71.2

49
 > 11 points (High level) 2 0.9

Total 226 100.0

According to Table 5.3, 71.2% of participants’ knowledge towards patient safety and

medical errors were among medium level (answered 6-11 points correctly) and only 0.9

answered all points correctly.

Table: ( 5.4): Mean score of students' knowledge towards medical errors and patient

safety

N Mean Std. Deviation

Mean score of students'

226 6.5177 2.14624

Table 5.4 showsthat the mean score of students' knowledge towards patient safety and

medical errors is 6.52 points with Standard Deviation (2.15).

5.4.1: Students’ knowledge

Table (5.5)shows the percentages and distribution of students according to their correct and

incorrectanswersrelated to the questions about knowledge.

Half of questions were answered incorrectly by more than 50% of the participants

50
 Table 5.5: Distribution of participants based on their answers to thequestionsabout

knowledge

Correct nswer Incorrect answer

No. Statement

Patient safety is the avoidance and prevention of adverse

1. 12 (5.3%) 214 (94.7%)
outcomes or injuries stemming from the process of health care.

Patient safety depend on reduction of risk of unnecessary harm

2. 157 (69.5%) 69 (30.5%)
associated with health care to an acceptable minimum.

Medical errors are the act of omission or commission in

3. planning or execution that contributes or could contribute to an 153 (67.7%)
73 (32.3%)
unintended result.

4. Patient safety is not a priority in health care. 174(77.0%) 52 (23.0%)

The main cause of medical error are overwork, stress nd

5. 161 (71.2%)
fatigue of health professionals. 65 (28.8%)

6. When I make an error I know how to report it. 162 (71.7%) 64 (28.3%)

7. After noticing a medical error, I know to whom to report it. 155 (68.6%)
71 (31.4%)

51
 Informing the right person about error that I make well help in
8. 41 (18.1%) 185 (81.9%)
protecting patient and myself.

My instructor has no role in dealing with error that I might

9. 161 (71.2%) 65 (28.2%)
make.

Study overload on nursing students may lead them to make

10. 68 (30.1%) 158 (69.9%)
errors.

Medical errors do not occur when the nurse's attention is

11. 99 (43.8%) 127 (56.2%)
interrupted by any cause.

When a nurse lacks sufficient knowledge and skills that does

12. 127 (56.2%) 99 (43.8%)
not lead him/her to make medical error.

Medical errors do not happen when health professionals lack

13. 124 (54.9%) 102 (45.1%)
the commitment to patient safety policies and procedures.

Medical errors have different types like medication errors ,

14. 186(82.3%) 40 (17.7%)
surgical errors, laboratory errors, and other types.

15. Medical errors can lead to a large number of adverse events. 32 (14.2%) 194 (85.8%)

16. Some patients are vulnerable to medical errors. 72 (31.9%) 154 (68.1%)

Being oriented to the patient safety rules with the emphasis of

17. 121(53.5%) 105 (46.5%)
the organization on it, would not result in good health care.

52
 Being knowledgeable to the principles of patient safety, will
18. 178 (78.8%) 48 (21.2%)
improve confidence between patient and health care provider.

According to Table (5.5), 59.7% of participants’ level of knowledge toward patient

safety and medical errors were among medium level (answered 6-11 points

correctly)and only 7.5 answered all points correctly.The main definition medication

errors were answered incorrectly by 67.7% of the respondents.Halfof questions were

answered incorrectly by more than 50% of the participants,thisindicatesthe need for

more employing on educating nursing students about patient safety and medical errors.

5.5Level of attitudes of nursing students toward patient safety and medical errors

Table (5.6)shows the total mean score of students’ attitudes towards patient safety and

medical errors which is(2.59)with standard deviation (SD): 0.705, which is considered as

low level.

Table (5.6): level of students’ attitudestoward patient safety and

medical errors (Total mean)

One-Sample Statistics

N Mean Standard. Deviation (SD)

Total mean of
226 2.590 0.705

53
Table 5.6shows the mean score levels of the students’ attitudes toward patient safety and

medical errors for each item in attitudes scale items which was among medium level as

illustrated in Table (5.6).

Table (5.7): Mean score levels and positive responses of students’ attitudes toward

patient safety and medical errors for each item in the attitudes scale

Attitudes scale items N Mean Std. Positive

Deviation response%

I believe that medical errors are a barrier between current care and
224 2.35 1.177 6.6%
best care.

I depend on medical training to understand concepts of patient

224 2.58 1.067 7.1%
safety.

I believe that human error is inevitable. 219 2.81 1.016 4.4%

I believe that knowledge about patient safety is only acquired from

223 2.98 1.134 7.5%
clinical experience.

I believe that changing in educational programs and training must be

improved to decrease the gap between knowledge and practice of 223 2.51 1.200 8.8%

patient safety.

I think that to make improvements in patient safety and decrease

224 2.56 1.162 5.8%
errors, new health policies must be formulated.

I believe that medical mistakes can be avoided. 223 2.46 1.101 4.0%

If one of my peers make unintentional error I will support him. 224 2.85 1.127 8.8%

54
 If one of my peers make unintentional error I will report about him. 224 2.55 1.098 4.0%

I believe that filling in reporting forms will help to improve patient

224 2.45 1.066 4.4%
safety.

I am able to report my own errors. 222 2.59 1.124 7.1%

If I keep learning from my mistakes, I can prevent incidents. 220 2.50 1.128 5.3%

It is important for me to learn how best to. 224 2.48 1.152 5.8%

acknowledge and deal with my errors by the end of nursing program. 224 2.54 1.244 10.2%

Figure 5.1 shows the distribution of students’ attitudes level toward patient safety and

medical errors , wich indicates that around 10%of the participants had high attitudeslevel,

48.88%had moderate attitudes level,and 40.8% had low attitudes level.

Figure 5.1: Distribution of students’ attitudes level toward patient safety and medical

errors

55
5.6 Relationship between personal characteristics (age,gender) and knowledge and

attitude of nursing students towardpatient safety and medical errors

Gender :Table 5.8, illustratesthat there was a slight differences between females and males

in the mean scores of knowledge and attitude variables. First: the total mean score

ofknowledge was (8.15for males vs. 6.86 for females) towardpatient safety and medical

errors.Second: the mean score of attitudes was (2.97for males vs. 2.47 for females)

towardpatient safety and medical errors . Males reported higher mean scores of knowledge

and attitudes toward medical errors and patient safety.

Table (5.8):T- test of level of students’ knowledge and attitudes toward patient safety

and medical errors in relation bygender

Sex N Mean Std. Deviation P-values

Total mean Male 53 8.15 3.28 0.001

score of Female 173 6.86 2.61

knowledge

Total mean Male 51 2.97 0.788 0.000

score of Female 173 2.47 0.638

Attitudes

Table 5.8, showsthat there was a highly significantdifferences in knowledge total mean

score (8.15for males vs. 6.86 for females)toward patient safety and medical errors (p-value

56
= 0.001), and there was a highly significant differences in attitudes total means score(2.97

for males vs. 2.47 for females) toward patient safety and medical errors (p-value = 0.000).

Age:Table (5.9)shows that there is a statistically significantdifferences in mean score of

students’knowledgetoward patient safety and medical errors according to age (p-value:

0.032) and non- statistically significant differences in mean score of students’attitudes (p-

value: 0.128), this indicatesthat there is an effect of age on the students’knowledge andno

effect of age on the students’attitudes.

Table (5.9):The results of the One Way AnovaAnalysis variable with students'

knowledge and attitudes toward patient safety and medical errors by age

ANOVA

Sum of Squares *df Mean Square F **Sig.

Between Groups 56.348 2 28.174 3.501 0.032

Knowledge Within groups 1794.400 223 8.047

Total 1850.748 225

Between groups 2.048 2 1.024 2.079 0.128

Attitudes Within groups 108.871 221 0.493

Total 110.918 223

*df, degree of freedom; **Sig, significant ≤ 0.05

57
5.7. Questions of knowledge regarding patient safety and medical errors

Table (5. 10) shows that 83.2% of participants reported that their academic program

included topics about patient safety, while 61.1% of participants reported that their

academic program includedtopics taboutmedical errors, and70 % of participants reported

that that those topicsareinsufficient. Furthermore, 58.4% of participants reported that

theyattended or participated in a training workshops about patient safety and 31.9%

participants reported that theyattended course/s about medical errors(Table 4.4).

58
 Table (5.10): Factors affecting the level of students’ knowledgetoward

patient safety and medical errors

Statement Frequency(N) Percent (%)

Yes 188 83.2

Have your program cover patient safety topics? No 38 16.8

Total 226 100.0

Yes 138 61.1

Have your program cover medical errors
No 88 38.9
topics?
Total 226 100.0

Yes 68 30.1

No 52 23.0

Do you believe this coverage is sufficient? do not know 105 46.4

Total 226 99.4

Missing system 1 0.6

Yes 132 58.4

Did you attended training workshop about
No 94 41.6
patient safety?
Total 226 100.0

Yes 72 31.9

Did you take a course about medical errors? No 154 68.1

Total 226 100.0

5.8The association between academic year level, exposure to medical errors, and

knowledge and attitude of nursingstudents towardpatient safety and medical errors

Acadimicyear:Table (5.11)shows that there is significant differences in the mean score of

students'knowledge by academic year level(8.11 for thirdyear level vs. 5.79 for fourthyear

level), and there is significant differences in the means score of students'attitudes (2.90 for

thirdyear level vs. 2.31 for fourthyear level).

59
Table (5.11):The results of the association of students' knowledge and attitudes

toward patient safety and medical errors by academic year level

Group statistics

Academic year N Mean Std. Deviation

level

Total score of mean Third year level 104 8.11 3.29

level of knowledge Fourth yearlevel 122 5.79 1.88

Total score mean level Third year level 104 2.90 0.834

of attitudes Fourth year level 120 2.31 0.412

60
 Table (5.12):The results of the (T-test) association of students' knowledge and

attitudes toward patient safety and medical errorsby academic year level

Independent Samples Test

Levene's t-test for Equality of Means
Test for
Equality
of
Variances
F Sig. t Df Sig. (2- Mean Std. 95%
tailed) Difference Error Confidence
Differenc Interval of the
e Difference
Lower Upper
Equal
41.35 .00 6.6 1.6288 3.0118
variances 224 0.000 2.32030 0.35090
3 0 12 1 0
assumed
Knowledge
Equal 157
6.3 1.5983 3.0422
variances not .67 0.000 2.32030 0.36551
48 7 3
assumed 9
Equal
78.41 .00 6.7 0.7539
variances 222 0.000 0.58401 0.08621 .41413
9 0 75 0
assumed
Attitudes
Equal 145
6.4 0.7619
variances not .65 0.000 0.58401 0.09004 .40605
86 7
assumed 4

Exposure to medical errors: Table (5.13)illustratesthe meansscores of students'knowledge

and attitudes by exposure to medical errors, there isno significant differences in the means

scores (6.72 for exposed vs. 7.00 for not exposed to medical errors),andthere is no

significant differences in means scores of students'attitudes by exposure to medical

errors(2.65for exposed vs. 2.53 for not exposed to medical errors).

Table (5.13): The results of the association between exposure to medical errors with

students' knowledge and attitudes toward patient safety and medical errors

61
 Group Statistics

Have you been exposed to N Mean Std. Std. Error

medical error in the clinical sites Deviation Mean

during your practice?

Yes 108 6.72 2.83118 0.27243

Knowledge
No 116 7.00 2.92960 0.27201

Yes 106 2.65 0.69081 0.06710

Attitudes
No 116 2.53 0.72036 0.06688

62
 Table (5.14):The results of the (T-test) of association between exposure to medical

errors with students' knowledge and attitudes toward patient safety and medical

errors

Independent Samples Test

Levene's t-test for Equality of Means
Test for
Equality
of
Variance
s
F Sig. t df Sig. Mean Std. Error 95%
(2- Differenc Differenc Confidence
tailed) e e Interval of the
Difference
Lower Upper
Equal
-
variance .4732
.001 .975 -.743 222 0.458 -.28640 .38545 1.0460
s 0
0
Knowledg assumed
e Equal
-
variance 221.68 .4722
-.744 0.458 -.28640 .38497 1.0450
s not 6 8
8
assumed
Equal
variance 1.28 .3087
.145 .704 220 0.201 .12172 .09492 -.06534
s 2 9
assumed
Attitudes
Equal
variance 1.28 219.48 .3084
0.200 .12172 .09474 -.06499
s not 5 0 4
assumed
Table 5.14shows that there is significant differences in means scores of students'knowledge

according to theuniversity (Mean score was 5.89 for Bethlehem University vs. 7.47 for Al-

Quds University), and in means scores of attitudes was 2.18 for Bethlehem University

students vs. mean score was 2.85 for Al-Quds University students).

5.9Summary:

63
From data analysis results, we found that there are a significant statistical differences in

students' knowledge and attitudes in regard to gender, academic year level and the

university where the students study. Morever, the findings revealed that that there were no

statistical significant differences in students' knowledge and attitudes byexposure to

medical errors, and there was a statistical significant deferencesaccording toage.

64
Chapter Six: Discussion, conclusion and recommendations

6.1. Introduction

This chapter presents discussion the main findings of the study. It discusses the level

knowledge and attitudes among nursing students towards patient safety and medical errors,

and associated factors in the University of Al-Quds and University of Bethlehem, West

Bank, Palestine.

In this current study the overall response rate is 67.7%

Three hundred and thirty four questioners were distributed at both Bethlehem and Al-Quds

Universities. The final study sample compromised 173 females (76.5%) and 53 males

(23.5%). The number of participated females in the study was higher than the males could

be related to the fact that most of students in both Universities are females. This is similar

to the study was conducted by Korhan and colleagues in 2016, which assessed

determination attitudes of nurses toward medical errors and related Factors, in which 86.8

% of participants were women. Both of two studies had a higherparticipated percent of

females than themales.

65
6.2. Knowledge level

The study found that, the mean score of students' knowledge towards medical errors and

patient safety is 6.5 points with Standard Deviation (2.14). A total of 72.1% of participants

were among the medium level of knowledge towards patient safety medical and errors

were among medium level (answered 6-11 points correctly ), and only 0.9 answered all

points correctly. These results were in accordance to study conducted bySen and colleagues

(2019), who found that a majority of students felt that their knowledge level on errors was

only average (medium). Most students showed their acceptable level of knowledge towards

patient safety and medical errors . This implies that teaching curriculum and methodology

need more attention and focus about patients' safety and medical errors. Another study was

conducted by Bari and colleagues in 2016, reported that, the knowledge of students about

medical errors was among good level.

66
6.3. Factors affecting participants' knowledge

The study assessedthe potential effects of somefactors that have an influence in improving

the participants' knowledge byanswering five statements including the following: Have

your program cover patient safety topics?, Have your program cover medical errors topics?,

Do you believe this coverage is sufficient?, Did you attended training workshop about

patient safety?, and Did you take a course about medical errors?. It was found that the

majority of participants agreed that their study program included topicsabout the patient

safety and medical errors (83.2% and 61.6% respectively), and 70% of participants agreed

that the study program is insufficient. Also 58.4% of participants answered "Yes" to the

statement" Did you attended training workshop about patient safety", and 31.9% of them

answered "Yes" to the statement" Did you take a course about medical errors".

The study results found that there is a focus on patient safety and medical errors in both

medical courses and clinical services, but this focus present in medical courses more than

clinical training, also this study shows that the coverage of this topic in both medical

courses or clinical services is not sufficient and need more attention and concentration from

technology departments in Palestinian Universities.

67
Our study reported that about 39% of participants reported disagree tothe statement “I

believe that changing in educational programs and training must be improved to decrease

the gap between knowledge and practice of patient safety“. This result correspond to a

study conducted by Nabilouand cooleguesin 2012 reported that 40.2% of participants

answeredthat changing in educational and training programs must be reformulated and

developed to decrease the gap in knowledge and interest toward patient safety, and new

health policies must be formulated.The growing need to equip clinicians with the

knowledge, attitudes and skills to improve patient safety has stimulated research efforts to

develop patient safety curricula and training interventions for medical students and

healthcare professionalslxvii. In response to the growing recognition of the importance of

patient safety, there is an increase in researchers who are interested in nursing students'

knowledge, attitudes and skills, about patient safetylxviii Some schools of nursing have

initiated a set of curricular innovations to increase patient safety competencies and the

inclusion of patient safety modules in medical school curricula has also been advocated

Validated tools [Medical Students' Patient Safety Questionnaire (Year 1)]' in a UK medical

school during 2008 were developed to assess levels of students' knowledge, attitudes and

skills within the student bodylxix. It has become clear that new educational programmes for

teaching medical students about patient safety are required. A study conducted by Flin and

colleagues in the UK in 2009, reported that medical students’ attitudes to good patient

safety practices were generally positive, but the students had little knowledge of how to

report errors and were unsure about what to do if a colleague made an error or if a patient

indicated that an error had been madelxx. To assess the suitability of the instrument beyond

the UK would require additional work.

68
Korhanand collegues (2016) found that 62.3% of participants received training sessions

related to medical errors applications, which is similar to the study in that most of

participant received training about medical errors, with a percent of 58.4%. This shows that

there is focus on training services on patient and medical errors but it's not sufficient. This

results differ from what was reported in a study results by Cauduroa et al (2015) which

presented that most of students reported that they had no formal training about patient

safety. Another study conducted by Cauduroa et al 2015 showed that the educational

programs need formulation of the subjects through different levels This in accordance to a

studyconducted byAghakouchakzade et al (2015) reported that there is a need for further

concentration in educational and training programs about medication errors and its adverse

drug events. These results in accordance with our study results, which reported that 83.2%

and 61.15 of participants reported that patient safety topics were included in the formal

program.More research is therefore needed in this field and training programmes in practice

would benefit from a multi-professional approach, in order for healthcare professionals to

implement evidence-based practice that addresses the delivery of safe care in a

comprehensive manner.

69
Thecurrent studyreported that most of respondentsdon’t depend on medical training to

understand the concepts related to patient safety and they participated in workshops and

training courses, in contrast toa study conducted by Elorrio et al (2016) that reported 53%

of participants depended on their medical training to understand the concepts aboutpatient

safety. On the other hand,the researcher found that most participants need more enough and

sufficient educational programs.Thisis similar to study resultsby Al-Khaldi (2011) in Saudi

Arabia reported that most of participants need courses and training about patient safety and

medical errors.

6.4. Attitudes level towards patients' safety and medical errors

In current study, the of students’ attitudes level toward patient safety andmedical errors was

among the medium level (M:2.59 and standard deviation (SD: 0.705)), but not within

positive responses since all of answers about attitude statements were among medium

level.This is in accordance to previous study rsults. A study conducted by Flottaand

colleguesin 2012 showed that there are positive attitudes about patient safety reported by

participants. A study conducted by Cauduroa and collegues in revealdthat some attitudes of

students showed uncertainty to patient safety in dealing with patients, and most of students

reported positive perception toward patient safety. Al-Khaldi (2011), found that physicians

in Aseer region have positive attitude toward patient safety. Health care professionals who

received no information about patient safety during their initial professional education had

more negative attitudes to teamwork climate, safety work climate, job satisfaction,

perceptions of management and working conditions than those who had. Also, health care

professionals who received no information about patient safety during their further or

70
continued education had lower ranked attitudes to safety climate, job satisfaction,

perceptions of management and working conditions than whose who had. Thus, education

about patient safety impacts upon the safety attitudes of health care professionalslxxi.

71
According to medical errors, the study revealdthat 65.1% of participants reporteddisagree

and strongly disagree to the statement (I believe that medical errors are a barrier between

current care and best care). The result is in contrast to a study results conducted by Nabilou

and colleagues (2012)reported that the students believe that medical errors are barriers

between the current care and the best care.

The current study found that around 50% of participants reported disagree and strongly

disagree in response to the statement (I believe that human error is inevitable. This is in

accordance to a study conducted by Elorrio et al (2016) reported that 59% of participants

believe that medical error is inevitable.Another study conducted by Aghakouchakzadeand

colleguesin 2015) reveald that 50% of participants reported that medication errors are

inevitable.

Also the study found that (53.1%) of participants were disagree and strongly disagree to the

statement (I believe that medical mistakes can be avoided). These results were in contrast to

the study results by Lun Lo and colleagues in 2018, reportedthat 70% of participantsbelieve

that medical mistakes can be avoidedlxxii.

72
71.2% of participants answered“No” to the statement "The main cause of medical errors

are overwork, stress and fatigue of health professionals"; and 69.9% of of participants "No"

answered to the statement "Study overload on nursing students may lead them to make

errors".56.2% of participants answered "No" to the statement "Medical errors do not occur

when the nurse's attention is interrupted by any cause " and56.2% of participants answered

"No" to the statement "When a nurse lacks sufficient knowledge and skills that does not

lead him/her to make medical error"; and 54.9% of participants answered "No" to the

statement "Medical errors do not happen when health professionals lack the commitment to

patient safety policies and procedures". These results were compared with the results

related studies and were different. Flottaand collegues study results in 2012 found that the

highest rates as the main causes of errors areoverwork, stress andfatigue of health

professionals, while a‘health professionals poorly skilled or experienced’ was the most

rated item among causes of error related to the human factors. Bari and colleguesstudy in

2016 reportedthat the causes of medical-related errors werefatiguedue to long duty hours

(65%), inadequate experience (52%), inadequate supervision (48%) ,and complex case

(45%).

73
Also the study investigated the reporting of medical errors by participants through different

items. It was found that 71.7% of participants answeredyes to the statement" When I make

an error I know how to report it"; and 31.4% answeredyes to the statement" After noticing a

medical error, I know to whom to report it".Also18.1% of participants answered yes to the

statement" Informing the right person about error that I make well help in protecting

patient and myself",and 71.2% of of participants answered "No" to the statement"My

instructor has no role in dealing with error that I might make".50.5% of participants

reported disagree and strongly disagree to the statement " I am able to report my own

errors". These results were compared to other results of previous studies.

Aghakouchakzadeand colleguesstudy results in 2015 revealedthat 55% of participants

reported that they have knowledgeabout the responsibility toward adverse drug events

reporting, while5% of participants reported that they have knowledgeabout methods of

reporting.

A study Senand colleguesin 2019 revealedthat 47% of respondents reportedthat they could

easily tell the others about an error they made, but on average, student opinion on blaming

others rather than focusing on the cause of error were evenly balanced between very low,

low, medium, and high. A majority of the students (83.6%) also felt that they are able to

make sure that patient safety is not put in jeopardy. Moreover, a majority (53%) of

respondents reported thatthe written reports will help in patient safety.

74
, The currentstudy found that 40.7% of participants reported disagree and strongly disagree

to the statement“support peers when they make an error”, and 28.3% of participants

reported agree and strongly agree to the statement. Only 19.4% of participants reported

agree and strongly agree to report unintentional errors of their peers. These results are

different when compared with the results of a study conductedby Almaramhyand collegues

in 2010 which revealedthat 76% -80.7% of participants reporte that they agreed that if one

of their peers make unintentional error they will support him.

In comparing to previous studies, the study findings correspond to findings of other studies

and in contrast to other studies results. Nabilou et al (2012) reported thatthat changing in

educational programs and training must be reformulated to decrease the gap in knowledge

and interest toward patient safety.a new health policies must be formulatedto make

improvements in patient safety and decrease errors. Our study reported that about 39% of

participants reported disagree tothe statement(I believe that changing in educational

programs and training must be improved to decrease the gap between knowledge and

practice of patient safety), in accordance with Nabiloustudy (2012) reported that with a

percent of 40.2%, it shows imply that there should be a development in educational and

training programs.

75
In this study, it was found that most of the students don’t depend on medical training to

understand concepts related to patient safety, in contrast with a study results conducted by

Elorrioand collegues in 2016 that reported that 53% of participants depend on their medical

training to understand concepts of patient safety. On the other hand researcher found that

most participants need more educational programs and these programs should be enough

and sufficient which.This in is accordance to study resultsby Al-Khaldiin 2011 in Saudi

Arabia thatreportedthat most of participants need courses and training about patient safety

and medical errors.

6.5. Effect of socio-demographic factors on knowledge and attitudes towards patients'

safety and medical errors

76
Finally in discussing the effect of the socio-demographic factors (independent variables) on

the dependent variable (knowledge and attitudes of nursing students towards medical errors

and patient safety), it is found that results were in accordance with some previous studies

and differ from others. A study conducted by BahramNabilouand collegues in 2015

showedthat there were no significant relationships between students' perception of patient

safety and their field of study, gender and year of entry to the university. The findings of

this study showed that there were significant relationships between students' interest in

patient safety and educational level and gender (p = 0.001), field of study (p = 0.017), and

year of entry to university (p = 0.003). Nursing students, males and junior and senior

students were more interested about patient safety education. The results of Pearson

product moment correlation coefficient showed a significant relationship between students'

perceptions of patient safety and their attitudes towards patient safety education (r = 0.344,

p = 0.01).

A study by NohaAsem et al. (2019) reported that there was no difference in knowledge,

attitude, and influence scores by different personal characteristics as gender, specialty,

workplace, and graduation year except for higher influence scores among physician who

have patient safety training courses (p = 0.016) .

77
NahedAlquwezandcolleguesconducted as tudy in 2015 reported that in the dimensions

‘working in teams’ and ‘communicating effectively’, and being females reported higher PS

competence than the male students (p <0.01, two-tailed test) in both the classroom and

clinical set-ups. Moreover, a strong negative correlation was established between the

nursing students’ academic level and self-reported PS competence in the clinical setting (r

= −0.35, n=191, p < 0.01). This suggests that as the students' progress to higher level of

nursing education, their perceived PS competence in clinical settings moderately

declines.Aghakouchakzade et al (2015) study shown that: there is no significant differences

appear on demographic characteristics of participants.

The study conducted by Blendonand collegues in 2002 shown that there was differences in

the view of both physicians and the respondents from public about the reasons behind

medical errors and their reduction strategies. The view of the majority of the two groups

that moving patients to a better level of care was not a radical solution to minimize medical

errors. The majority supported the idea of sanctions and medical accountability for service

providers who caused terrible damage.

6.6. Conclusion

78
This study was conducted to assess the level of knowledge and attitude of nursing students

toward patient safety and medical errors in Palestinian Universities. The study utilized a

cross sectional- design using patient safety and medical errors questionnaire, in addition to

the socio-demographic questions. The results show that students had knowledge about

patient safety and medical errors but this knowledge wasn’t enough. They had a positive

attitude toward patient safety and medical errors but this area needs more attention. Also it

shows that educational programs and clinical training need more focusing about this topic.

They must put clear policies and procedures so students can understand its concepts.

Reporting of medical errors should be a priority, students need to identifying policy of

reporting and all its issues. Causes of errors must be taken within consideration in

educational programs about patient safety and medical errors.

Patient safety is a fundamental principle of health care. One of the definitions of patient

safety is the prevention of errors and adverse effects to patients associated with health

care.In developed countries, one out of ten patients is harmed while receiving hospital care

with higher probabilities in developing countries (Patient safety. [Internet]. 2011. Available

from http://www.euro.who.int/en/what-we-do/health-topics/Health-systems/patient-safety).

A study estimated ten to eighteen percent of hospitalized patients are injured due to medical

errorslxxiii. The burden of unsafe care is unclear in developing countries where inappropriate

infrastructure, technology and shortage of human resources have caused higher possible

risk of harm to the patient in hospitals and in primary care compared with developed

countries which have sufficient funds and modern technologylxxiv. In Palestine, a survey

79
using a global trigger tool reported that one out of seven patients is suffered from harm and

59.3% of these had been preventablelxxv.

The Palestinian Universities should be encouraged to use knew policies and strategies when

dealing with patient safety and medical errors topics to improve students level of attitude

and knowledge about these topics, They must increase awareness of new information (up to

date ). Also, the administrative staff and policy makers in the Palestinian Universities

should regulate courses and workshops periodically to both students and teachers. A clear

policy should informed about patient safety and medical errors topics that must be covered

in educational programs and clinical training.A failure to rescue patients from the harm is

strongly linked to nursing personnel. Nurses make up the largest proportion of health care

professional, and providing over 80% of all care episodes worldwidelxxvi. Thus nurses are

competent to identify treatable complications such as gastrointestinal bleeding and

respiratory problems during patient assessment,so, nurses are often the first line of

intervention to rescue a patient from harmlxxvii. Moreover, nurses improve patient safety by

engaging with patients and patients’ families in a respect manner, checking procedures,

learning from errors, and communicating effectively with health care team memberslxxviii.

80
The growing need to equip clinicians with the knowledge, attitudes and skills to improve

patient safety has stimulated research efforts to develop patient safety curricula and training

interventions for medical students and healthcare professionalsIn response to the growing

recognition of the importance of patient safety, there is an increase in researchers who are

interested in nursing students' knowledge, attitudes and skills, about patient safety (Schnall

et al; 200) Some schools of nursing have initiated a set of curricular innovations to increase

patient safety competencies and the inclusion of patient safety modules in medical school

curricula has also been advocated Validated tools [Medical Students' Patient Safety

Questionnaire (Year 1)]' in a UK medical school during 2008 were developed to assess

levels of students' knowledge, attitudes and skills within the student body (WHO, 2009). It

has become clear that new educational programmes for teaching medical students about

patient safety are required. A study conducted by Flin and colleagues in the UK in 2009,

reported that medical students’ attitudes to good patient safety practices were generally

positive, but the students had little knowledge of how to report errors and were unsure

about what to do if a colleague made an error or if a patient indicated that an error had been

made (Flin et al. 2009). To assess the suitability of the instrument beyond the UK would

require additional work.

6.7 Recommendations

This study can serve as a baseline for future studies to examine the effects of socio-

demographic factors on nurses' knowledge and attitudes toward patient safety and medical

errors. Educators should focus on evidence-based practice and include multi-professional

learning in order to develop health care professionals’ skills to work as coordinated team to

81
ensure patient safety. In continuing education and management practice, regulations should

be considered which promote patient safety. Thus, further research is needed to focus on

specific areas related to health care professionals’ knowledge and skills related to patient

safety.A literature review study was conducted by Brasaite , Kaunonenand Suominen

in2015, revealedthat all of the health care professional groups in the study had gaps in their

knowledge of patient safety issues, and this challenges managers to create opportunities for

the staff to update their knowledge and skills regarding patient safety.

Research indicates, however, that healthcare systems face a big challenge to ensure safe

care for patients and prevent harm. Thus, it is important to identify the weakest areas in the

knowledge of healthcare professionals (Schnall et al. 2008). A study conducted by Alper

and colleagues in 2009 to describe the patient safety curricula at U.S. and Canadian medical

schools and to identify factors associated with adoption of these programs, reported that

healthcare professionals' attitudes related to patient safety were positive, while the

healthcare professionals' knowledge of patient safety is still deficientlxxix. However, it has

also been demonstrated that there are ways to add to healthcare professionals' knowledge

related to patient safety, and to make improvements by means of a safety training course,

and more research on long term improvement of knowledge is neededlxxx. Furthermore, by

ensuring knowledge sharing, undesirable patient outcomes might be avoided if the free

reporting of events related to patient harm is promoted. There is a need to highlight the

requirement of a no punitive culture in healthcare systems. More research is therefore

needed in this field and training programmes in practice would benefit from a multi-

professional approach, in order for healthcare professionals to implement evidence-based

practice that addresses the delivery of safe care in a comprehensive manner.

82
Ensuring patient safety is a constant concern of Registered Nurses to enable safe nursing

practicelxxxi. Measuring and improving safety attitudes among healthcare providers is an

important strategy for promoting a safe environment for patientslxxxii. For example, nursing

care is seen as vital in the delivery of safe care (Page, 2004). Properly prepared nurses with

their knowledge, attitudes and skills are needed to improve patient safety and to ensure

quality of patient care and decrease morbidity and mortality rateslxxxiii. To assist medical

schools in introducing patient safety teaching, the World Health Organization (WHO)

released a new curriculum for teaching medical students about patient safety.

Furthermore, it is recommended that the initial exposure to patient safety should occur early

in undergraduate and graduate medical education programs and be ongoing throughout

medical education (Association of American Medical Colleges.2003) In literature, there has

been less attention paid to the perception of patient safety or medical error by medical

students and to the role they could have in error preventionlxxxiv. Assessment students’

attitude about the patient safety and medical errors is necessary to have a baseline data in

order to design and implement relevant educational programs. Attitudes drive behavior, if

we can change a person’s attitude we may change his or her behaviorlxxxv.

6.8. Limitations of the study

83
The studies were limited by their cross-sectional designs, which prevented us from

establishing definitive inferences about the causality. The data were obtained through self-

report, which may be affected by response bias (Mcclafferty et al.,2000). The associations

identified may be difficult to interpret as it is susceptible to bias due to low response and

misclassification due to recall bias.

Absence of approval by Al-Najah University to distribute questionnaires among

students,we were unable to access information from nurses students from, Al-Najah

University, this might be affect the response rate, and the missing population should could

create selection bias.

Shortage of published studies related to patient safety and medical errors in Palestine and

the Arab countries.

84
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104
.

105
Appendices

Appendix 1: Research Instruments (questionnaire).

106
 ‫جامعة القدس‬

‫كلية الصحة العامة‬

‫برنامج ماجستير السياسات واالدارة الصحية‬

‫استبانة‬

‫عزيزتي الطالبة ‪/‬عزيزي الطالب ‪:‬‬

‫ﺗﺤﯿﺔطﯿﺒﺔ ‪.....‬‬

‫أنا الطالبة أريج جوابرة طالبة ماجستير من كلية الصحة العامة ‪ ،‬برنامج السياسات واإلدارة الصحية بجامعة القدس‪،‬‬

‫أقوم بإعداد رسالة الماجستير بعنوان‪Level of knowledge and attitude among nursing senior":‬‬

‫‪"students toward patient safety and medical errors‬‬

‫"مستوى معرفة وتوجهات طلبة التمريض مستوى سنة ثالثة ورابعة حول سالمة المرضى واألخطاء الطبية"‬

‫وذلك من اجل استكمال متطلبات درجة الماجستير‪ .‬لذا نرجو من حضرتكم التعاون باإلجابة على أسئلة االستبانة ‪،‬علما‬

‫بأن المشاركة طوعية وأن هذه المعلومات ستستخدم لغرض البحث العلمي فقط وستحاط بالسرية التامة ‪،‬لذلك ال داعي‬

‫لكتابة االسم أو ما يشير إليك‪ ،‬شاكرة لكم حسن تعاونكم‬

‫المشرفة ‪ :‬دكتورة ‪.‬أسما االمام‬ ‫الطالبة ‪ :‬أريج جوابرة‬

‫‪:Section One: Socio-Demographic Data‬‬

‫‪107‬‬
108
 This section deals with personal data. Please mark with cross (X) the one answer to each

question which most accurately represents your situation:

1) Gender:

A. Male ( ) B. Female ( )

2) Age:________

3) Marital Status:

A. Single ( ) B. Married ( ) C. Engaged ( )

D. Widowed( ) E. Divorced( ) F. Separated ( )

4)Academic Year:

A. 3rd year ( ) B. 4th year ( )

5) Have your program cover patient safety topics ?

A. Yes ( ) B. No ( )

6) Have your program cover medical errors topics ?

A. Yes ( ) B. No ( )

109
 7)Do you believe this coverage is sufficient ?

A. Yes ( ) B. No ( ) C. I don’t know ( )

8) Have you been exposed to medical errorin the clinical sites during your practice?

A. Yes ( ) B. No ( )

9) Your current program is?

A. Nursing ( ) B. Midwifery ( )

10)Cumulative average:

A. Major _____

B.GPA (Grade Point Average): ______

11)University:

A. Bethlehem University ( ) B. Al-Najah University ( )C. Al-Quds

University ( )

12) Did you attended or participated in a training workshop about patient safety?

A. Yes ( ) B. No ( )

13 ) Did you take a course about medical errors ?

A. Yes ( ) B. No ( )

Section Two : Knowledge of nursing students toward patient safety and medical

errors:
110
 This section deals with Knowledge of nursing students toward patient safety and medical

errors. Please mark with cross (X) the one answer to each question which most accurately

represents your situation:

111
 Yes No
Number Statement

Patient safety is the avoidance and prevention of

adverse outcomes or injuries stemming from the
process of health care

Patient safety depend on reduction of risk of

unnecessary harm associated with health care to an
acceptable minimum

Medical errors are the act of omission or commission in

planning or execution that contributes or could
contribute to an unintended result

Patient safety is not a priority in health care

The main cause of medical error are overwork, stress

and fatigue of health professionals

When I make an error I know how to report it

After noticing a medical error, I know to whom to

report it

Informing the right person about error that I make well

help in protecting patient and myself

My instructor has no role in dealing with error that I

might make

Study overload on nursing students may lead them to

make errors

112
Medical errors do not occur when the nurse's attention
is interrupted by any cause

When a nurse lacks sufficient knowledge and skills that

does not lead him/her to make medical error

Medical errors do not happen when health

professionals lack the commitment to patient safety
policies and procedures

Medical errors have different types like medication

errors , surgical errors, laboratory errors , and other
types

Medical errors can lead to a large number of adverse

events

Some patients are vulnerable to medical errors

Being oriented to the patient safety rules with the

emphasis of the organization on it , would not result in
good health care

Being knowledgeable to the principles of patient

safety, will improve confidence between patient and
health care provider

113
 Section 3:Attitudes of nursing students toward patient safety and medical errors

 This section deals with attitudes of nursing students toward patient safety and medical

errors. Please mark with cross (X) the one answer to each question which most accurately

represents your situation:

Number Statement Strongl Agree Neutral Disagre Stron

y agree e y
disag
e
I believe that medical errors are a
barrier between current care and best
care
I depend on medical training to
understand concepts of patient safety
I believe that human error is
inevitable
I believe that knowledge about
patient safety is only acquired from
clinical experience.
I believe that changing in educational
programs and training must be
improved to decrease the gap
between knowledge and practice of
patient safety
I think that to make improvements in
patient safety and decrease errors ,
new health policies must be
formulated
I believe that medical mistakes can
be avoided
If one of my peers make
unintentional error I will support him
If one of my peers make
unintentional error I will report about
him
I believe that filling in reporting
forms will help to improve patient
safety
I am able to report my own errors

114
 If I keep learning from my mistakes,
I can prevent incidents
It is important for me to learn how
best to
Acknowledge and deal with my
errors by the end of nursing program

Appendix2: Ethical approval

115
Appindex3:Name of Experts:

116
-Mrs.EtafMaqboul, a lecturer in Bethlehem University, Palestine

-Mr.HazemAl-Najarlecturer in Al-Quds University, Palestine

-Mr.MuradAmro-Quality and infection control advisor at Al-AhliHospital, Hebron,

Palestine

- Mrs. Salam Al-Khatib, Dean of Nursing College in AL-Quds University), Palestine

-Dr.YousefJaradat,Lecturer at the Faculity of Nursing and Health Sciences at Bethlehem

University.

117
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