International Journal of Africa Nursing Sciences 14 (2021) 100278

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Patient awareness and role in attaining healthcare quality: A qualitative,

exploratory study
Wudma Alemu a, *, Eshetu Girma b, Tefera Mulugeta a
a
Department of Nursing, School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, P.O. Box: 4412, Addis Ababa, Ethiopia
b
Post Graduate Unit, School of Public Health, College of Health Science, Addis Ababa University, P.O. Box: 378, Addis Ababa, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Healthcare quality, a critical component of healthcare services, is a demanding product of the joint
Hospital efforts of the healthcare stakeholders; yet, the quality of health care is often lower than expected. It has been
Patients reported that patients who feel empowered play an important role in the quality of care delivery. In Ethiopia, no
Quality
study has examined healthcare quality from the patient’s perspective. In this study, we explored whether or not
Ethiopia
patients were aware of healthcare quality, as well as their role in improving the quality of care.
Method: This descriptive, exploratory study included in-depth interviews with 12 inpatients using a semi-
structured interview guide. Participants were recruited from the inpatient units of a large referral hospital in
Addis Ababa, Ethiopia using purposive sampling with maximum variation. Field notes were collected and in­
terviews were audio-recorded. Data were coded, transcribed verbatim, translated into English, and analyzed
thematically using OpenCode.
Results: All participants were aware of problems with healthcare quality and occurrence of medical errors. Most
participants rated healthcare quality as poor or marginally good. Participants did not know their role in the
pursuit of healthcare quality; most assumed a passive role in care delivery.
Conclusion: Overall, study participants were not satisfied with the quality of their care during hospitalization.
Patient satisfaction can be improved through patient empowerment and engagement in the care delivery process.

1. Introduction
The World Health Organization (WHO) (2009) has defined the
quality of healthcare as, “The extent to which healthcare services pro­
vided to individuals and patient populations improve desired health
outcomes…,” a meaning that differs considerably among patients and
care providers (Guijarro et al., 2010; Hartnell et al., 2006; Mazor et al.,
2012). Over time, hospitals appear to have improved the quality of care
compared to past years due to the evolving knowledge of disease pro­
cesses, the establishment of reliable healthcare systems, and advance­
ments in biotechnology (AHRQ, 2019; Garrett and Craig, 2007; Tran
et al., 2016). Yet, some hospitals continue to struggle to maintain an
acceptable level of healthcare quality (Donabedian, 2003; Duffy, 2013;
Hughes, 2008) and, as a result, many patients question the quality of
care that they receive (Mazor et al., 2012).
Quality metrics typically include the frequency of medical errors or
an unexpected outcome, which is often attributed to deviations from the
right plan of care or execution of a wrong care plan (WHO, 2009).
Medical errors are a threat to patient safety and care quality, and are
among the leading causes of patient morbidity and mortality globally
(Jha et al., 2013; Slawomirski et al., 2017). Medical errors result in a
substantial increase in healthcare cost due to extended lengths of stay
and additional treatments as well as an increase in poor patient out­
comes and death (Kobewka et al., 2017; Welzel, 2012). Reports suggest
that 8%–12% of hospital admissions result in a medical error (WHO
Europe, 2017); other reports suggest that medical errors account for
more than 5% of in-hospital deaths (Kavanagh et al., 2017; Kobewka
et al., 2017; Matlow et al., 2014). Further, on average, 10% of patients
who experience a medical error will require a prolonged length of stay,
which considerably increases healthcare costs (Welzel, 2012; WHO,
2017).
How we measure quality has been a topic of debate, but recently,
medical cost financers (such as patients and health insurance com­
panies) and hospital administrative personnel have focused on patient

* Corresponding author at: Department of Nursing, School of Nursing and Midwifery, College of health sciences, Addis Ababa University, P.O. Box: 4412, Addis
Ababa, Ethiopia.
E-mail address: wudma.alemu@aau.edu.et (W. Alemu).

https://doi.org/10.1016/j.ijans.2021.100278
Received 31 May 2019; Received in revised form 1 December 2020; Accepted 11 January 2021
Available online 16 January 2021
2214-1391/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
W. Alemu et al.
satisfaction as a metric in their quest for quality (AHRQ, 2018, 2020;
British Medica Journal, 2009; Duffy, 2013; Wachter, 2008; WHO, 2018).
Though many believe that patient satisfaction is subjective, others have
begun to use this metric widely. There is some consensus that patient
satisfaction is partly driven by the extent to which patients are involved
in the process of care (Grøndahl et al., 2018; Siriwardena and Gillam,
2014). The practice of shared decision making between patients and
care providers has been linked to improved patient outcomes (Castro
et al., 2016; Gillespie & Reader, 2018; Harvard School of Public Health,
2014), mainly through improvements in patient satisfaction scores
(Grøndahl et al., 2018; Weingart et al., 2011). Shared decision making
improves one’s ability to identify and report (Brabcová et al., 2014;
Davis et al., 2012; Harvard School of Public Health, 2014; Spath, 2004)
and manage medical errors (Brabcová et al., 2014; Hibbard et al., 2005;
WHO, 2016), which ultimately contributes to improvements in the
overall quality of care (Groene, 2011; Weingart et al., 2011; WHO,
2016). Despite evidence that nearly all patients are willing to participate
in a shared decision-making process (Schoenfeld et al., 2018), 35–53%
of patients report that they are not consulted in the process of care
(European Patient’s Forum, 2017; Gillespie & Reader, 2018).
Patient empowerment is critical for a successful shared decision-
making process, especially in the detection and management of medi­
cal errors (European Patient’s Forum, 2017; WHO, 2016). This is
because empowerment increases patient awareness regarding the pro­
cess of care, including the possibility of medical errors and the associ­
ated sequelae (IHI, 2017; Mazor et al., 2009) as well as the role of
patients in the reduction and elimination of medical errors (Karch, 2015;
Schoenfeld et al., 2018; Wilde-Larsson & Larsson, 2008). This process
includes an educational component, wherein patients are informed of
their disease process as well as specific diagnosis and treatment options
(Britten, 2009; Muhrer, 2014).
Few studies in Africa have examined patients’ perspective about the
quality of healthcare, satisfaction with the care, and medical errors.
Recent scholarship show that most patients treated in Africa believed
they were receiving poor quality care (Katuti, 2018; Teshome et al.,
2019). One study, for example, revealed that over two-thirds of patients
knew about medical errors; nearly half believed that medical errors
occurred to them and knew that the errors could have serious health
consequences (Ushie et al., 2013).
The quality of healthcare is a major concern for healthcare facilities,
system administrators, patients and families alike. Nonetheless, no study
so far has examined patient involvement in the care process nor their
roles in care quality in Addis Ababa, Ethiopia. We, thus, conducted this
study to explore patients’ knowledge base and the degree of involve­
ment in the quest for care quality and the reduction or elimination of
medical errors in hospitals in Addis Ababa, Ethiopia.
This study considered healthcare quality as an outcome of collective
efforts by patients, care providers and healthcare systems. It, thus,
assumed that patients could play key roles in realizing optimal care
quality. The roles, in turn, depend heavily on the patients’ under­
standing of the care quality as well as the value of their contribution to
materializing the quality. This study, therefore, explored the patients’
perception of and contribution to care quality using the interactive
multidimensional (patient-provider-hospital) theoretical model (Azam
et al., 2012; Brown et al., 2018; Mosadeghrad, 2012, 2013, 2014).
2. Materials and methods
2.1. Approach, setting and participant recruitment
This was a descriptive, exploratory study that examined patients’
knowledge of healthcare quality, medical errors and role in the man­
agement of medical errors. It was conducted in a purposely selected,
800-bed referral hospital in Addis Ababa. The hospital has an annual
capacity of treating around 400,000 patients referred from all over the
country. The study interviewed 12 in-patients recruited from five major
2
International Journal of Africa Nursing Sciences 14 (2021) 100278
wards: medical, surgical, gynecology and obstetrics, oncology, and or­
thopedic wards. The participants were recruited through purposive
sampling with maximum variation: chosen from both sexes, wide age
range (from 19 to 74 years), several inpatient units, variable illness types
and severity, and at different time of the day (morning, lunchtime and
afternoon). The inclusion criteria for the participants were that they
were 18 years or older, admitted to in-patient units, understood
Amharic, and able to make decisions and provide informed consent. The
data were collected from 10 June to 17 July 2019.
2.2. Data collection tool
A study team, composed of three authors, collected the data through
in-depth interviews using a semi-structured interview guide adapted
from earlier studies (Burroughs et al., 2007; Harvard School of Public
Health, 2014; Hibbard et al., 2005; Mazor et al., 2009). The guide
contained eight general, open-ended questions that explored patient
awareness surrounding the quality of hospital care, medical errors, and
roles that they, as patients, could play in the reduction of medical errors.
Back translation was used to prepare the interview guide: it was pre­
pared initially in English, and then translated to Amharic (local lan­
guage) and then back to English. The Amharic version was used for the
final study.
2.3. Data collection procedure
Two interviewers were involved in each interview by alternating the
authors. The interviews were conducted in the inpatient units of the
hospital where the participants were receiving care. Upon entering the
participants’ rooms, the interviewers greeted the patient, introduced the
study, and then asked if he/she would like to take part in this study. The
participants were also asked if they would like to take some time to
decide whether to participate, but none of them took more than five
minutes to decide.
Those who agreed to participate in the study and met the inclusion
criteria were briefed about the purpose of the study. It was explained to
them that they had the right to participate, refuse, or withdraw from the
study at any time; and that all information collected would be kept
confidential. In addition, it was explained to the patients that refusing to
participate or withdrawing from the study was their right as research
participants and would be an acceptable option (Annex A). Moreover,
the participants were allowed to decide on the presence or absence of
their relatives during the interview, where 11 of them preferred to be
interviewed in the presence of their relatives. Then, those who fully
understood their rights and agreed to participate in the study were asked
to sign an informed consent form. The interviews were conducted in the
absence of care providers. The interviewers paused the interview if it
was time for a patient to receive treatment, or would like to take break or
recover from any discomfort.
The 8-question, semi-structured interview guide was used for each
study participant. The interviewers used the open-ended questions to
elicit specific participant responses, and followed with probing for
further clarification if needed. The interviews were conducted on a one-
to-one basis at different times (morning, lunchtime, and afternoon) of
the day and lasted 45 min on average. Eleven participants allowed their
responses to be audio-recorded, and field notes were taken in addition.
Two participants did not allow their responses to be audio-recorded: for
these interviews, detailed field notes were taken. However, one of the
two field notes lacked sufficient details and was excluded from the
analysis. The interview process concluded with one more interview after
reaching data saturation, as evidenced by redundancy of information.
2.4. Data management and analysis
Upon completion of the interview process, two of the study team
members assigned a unique code to each record (audio recording and
W. Alemu et al. International Journal of Africa Nursing Sciences 14 (2021) 100278

field notes) taken from each interview. The recordings from each 3.1. Demographic characteristics of participants
interview were kept in a separate folder. Each folder was coded
uniquely, and then deposited in a repository. The coding team checked Participants ranged in age from 19 to 74 years, half were women, and
each other’s coding for accuracy. Whenever there was a discrepancy in roughly two-thirds reported that they had completed a secondary or
their coding, the coders would discuss and resolve it. The audio- tertiary education program. Three-quarters of the participants were in­
recordings were transcribed verbatim, and then translated into En­ patients in medical, oncology, and surgical wards (Table 1).
glish. All the interview transcriptions were entered into OpenCode for
coding and analysis.
3.2. Patient awareness about care quality
Data analysis involved both quantitative and qualitative methods
(Denzin and Lincoln, 2018; Flick, 2014). The quantitative analysis of
The study team assessed the knowledge base of the study participants
responses to some concepts such as perception of care quality and
on care quality by asking them to describe care quality in their own
severity of medical errors as they originally appeared would make the
words, and to list the criteria they use to choose a hospital for their
subsequent findings difficult to understand and use. Hence, the analysis
healthcare needs. Then, we compared their descriptions conceptually
grouped similar responses into one to make the findings simple for
and literally with that of the WHO. The majority of the study partici­
comprehension and use. The qualitative analysis explored the partici­
pants were able to describe care quality using at least one of the key­
pants’ awareness about care quality, medical errors and managing the
words and phrases that are in the WHO standard definition, such as
errors. The quantitative analysis measured the patients’ level of
safety, effectiveness, cordial reception, timeliness, and active involve­
awareness about care quality, magnitude of medical errors and role in
ment (WHO, 2009).
managing medical errors: it estimated the proportion of responses per
All the participants listed care quality, the reputation of a hospital,
code, categories, and sub-themes.
safeness of care or a combination of these as criteria for selecting hos­
After repeatedly listening to five of the audio recordings, along with
pitals. For example, when a 49-year-old male cancer patient was asked
reading the translations and field-notes carefully, two of the researchers
about the criterion he uses for choosing a hospital, he replied, “I mostly
developed codes representing similar or identical responses. The codes
use the quality of care as a criterion.” When asked to elaborate on what he
were developed deductively by tracing the topics in the interview guide.
meant by “quality of care,” he said, “If a doctor properly identifies my
Conceptually similar codes were unified into a category, categories into
problem and gives me the right treatment, then that is quality care. If the
a sub-theme, and sub-themes into a theme. Codes and themes were
treatment does not cause me any injury or discomfort, that also is quality
refined, modified and even changed as more data were included in the
care. If the treatment eradicates my health problem, it is quality care. It also is
analysis.
quality care if the professionals treat me like a human rather than like a
subject or an object.”
2.5. Rigor of the study
Another participant, who reported using “reputation” as a criterion
for choosing a hospital, described “reputation” as, “…If a hospital has
Several measures were taken to ensure the rigor of the study: the
good reputation, it means that it is working hard… Good reputation is
participants were recruited through purposive sampling with maximum
tantamount to high-quality care. If the care is high quality care, it is safe. …”
variation to increase the depth and breadth of the patients’ views. The
Similarly, one other participant, who reported using “safety of care” as a
study guide was adapted from previous studies and pilot tested with
main criterion for choosing a hospital, described “safety” as, “… the
three in-patients at a regional hospital in Addis Ababa, Ethiopia. The
professionals do not make mistakes while performing procedures on me…I
pre-test led to the removal of one redundant question and slight changes
mean, getting harm-free care.”
to the content of almost all the general questions, including adding an
alternative word (‘describe’) to the first guiding question, and splitting
the third guiding question into two (Annex B). It also helped the team to 3.3. Patient satisfaction
reconsider the interview approach.
The first draft of the study report was sent to two of the participants Using a 5-point Likert type scale, the interviewers asked the partic­
to find out if it sufficiently represented their views, which they positively ipants to rate the quality of care they received in the current hospital.
affirmed. Furthermore, two colleagues compared the final report with The possible responses on the scale ranged from “bad” to “very good,”
the interviews and concluded that the final report adequately repre­ and were condensed into three categories: “satisfactory,” “neutral” or
sented the opinions of the participants. A record of the authors’ onto­ “unsatisfactory.” Accordingly, the ‘very good’ and ‘good’ responses were
logical and epistemological viewpoints was also compiled to bracket out put under the first category, ‘indifferent’ under the second (which had
researcher biases from preconceptions. The interviews were augmented
with notes taken during the interview. Table 1
Demographic characteristics of participants (n = 12).
2.6. Ethics of the study Variables Categories Frequency (%)

Age In year <20 1 (8.33)

All the study participants were protected, as required for human 20–30 3 (25)
subjects. The report kept the identity of the hospital confidential at the 30–40 2 (16.67)
hospital administrators’ request. The IRB of the College of Health Sci­ 40–50 2 (16.67)
ences at Addis Ababa University cleared the study of any ethical con­ 50–60 2 (16.67)
2 (16.67)
cerns (letter Ref. No: Prv/048/11). The team initiated the interview
>60
Sex Female 6 (50)
after the hospital under study permitted the study to move forward as Male 6 (50)
planned. Educational status Unable to read/write 1 (8.33)
Primary education 3 (25)
3. Results Secondary education 5 (41.67)
Tertiary education 3 (25)
Wards (Dx) Medical 3 (25)
The findings are organized around four subsections. Obstetrics/Gynecology 2 (16.67)
Oncology 3 (25)
Orthopedic 1 (8.33)
Surgical 3 (25)

3
W. Alemu et al.
zero count), and ‘bad’ and ‘very bad’ under the third. Based on these
categories, nearly half of the participants rated the quality of care in the
current hospital as “unsatisfactory.” One participant described the
quality of care he received as, “Not bad. I do not feel good about the length
of time I waited to get treatment. Even after such a long wait, the quality of
care I got is not satisfying.” How participants rated the quality of care they
received varied by inpatient units. Patient satisfaction was the lowest in
the oncology unit, where a 49-year-old cancer patient, for example,
rated it as, “Not good. It took me many weeks to get treatments… I am still
waiting, but the disease is progressing. My hope for a cure has died out little by
little.”
3.4. Patients’ awareness about medical errors
This study assessed patients’ awareness of medical errors by
exploring their understanding of errors, the existence of errors and the
consequences of errors.
3.5. Patients’ understanding of medical errors
Participants’ responses on their understanding about medical errors
were grouped into “aware” or “unaware” categories. A response was
assigned to the “aware” category if it described a medical error as a
professional mistake, a wrong act, a wrong procedure, or patient harm
due to an erroneous diagnostic or therapeutic procedure. Eight of the 12
responses met these criteria, and thus went to the aware category.
Among the responses in this category include that of a 23-year-old
participant who described a medical error as, “… when the care pro­
viders give you a wrong medicine or suture-close a surgical opening by leaving
materials inside or conduct surgery on the wrong site…” Similarly, a 39-
year-old participant, with a response in the aware category, described
a medical error as, “…when a patient gets harmed because of a mistake the
health professionals make…”
The remaining four responses went to the ‘unaware’ category. The
responses under this category showed that the responders either had
never heard about a medical error or had heard but were unable to
describe it. For example, a 65-year-old patient replied, “I’m not sure
about it…I have never heard about it before.” Likewise, another participant
replied, “…not sure that I am aware of it. I think I heard about it on TV or
radio, but not aware of what it actually means.”
3.6. Patients’ views on occurrence of medical errors
As to the occurrence of a medical error, three-quarters of the par­
ticipants presumed that it occurs in the current hospital. When a 74-
year-old cardiac patient was asked for his remark on occurrence of
medical errors in the current hospital, he stated, “Yes, it occurs in every
hospital, including this one. Its humans who work in here, and all humans
make mistakes…” Likewise, a 29-year-old patient replied to the above
question as, “Yes. Why not? … Its occurrence is inevitable despite the
industrious efforts the health professionals make to avoid it.”
The study participants were additionally asked if they had experi­
enced a medical error or heard of other patients who sustained medical
errors. Seven participants reported either having a history of or heard of
other patients who sustained medical errors. For example, a 27-year-old
respondent replied to the ‘experience’ related question by saying, “Yes, it
happened to me. Because of a lag in initiating my therapy, the disease is
progressing and tormenting me… The care providers, who referred me to this
hospital, took a lot of time on treating me for other illness, as they did not
know that it was cancer… If they had soon identified it correctly and referred
me right away, my chance of cure could have been much higher.”
3.7. Patients’ perception of severity of medical errors
As part of our interviews, the study participants were challenged
with the question, “how serious could the consequences of medical
4
International Journal of Africa Nursing Sciences 14 (2021) 100278
errors be?” Their responses ranged from a mere financial cost to death:
these were grouped into “severe” or “very severe” category. Responses
that included death were assigned to the latter category, to which 10 of
the 12 responses belonged. When the above question was posed to a
cancer patient, she replied, “…it could be fatal. I may die soon if I do not get
the treatment I need. You know cancer is a deadly disease if not treated in
time. I may not survive even after getting a treatment if the disease spread to
other parts of my body…”
3.8. Management of medical errors
In this study, management of a medical error is defined as the pre­
vention of an error occurrence, and once an error occurs, mitigating its
consequences. We assessed the patients’ understanding of their role in
the management of medical errors through assessing their understand­
ing of three constructs: 1) the role they play in the management of
medical errors, 2) the importance of an accurate description of an
illness, and 3) the significance of their active involvement in the care
delivery process.
To assess the participants’ understanding of their role in the man­
agement of medical errors, we asked them, “How much do you think you
can contribute to the prevention and control of medical errors?” The
subsequent responses were measured on a 7-point Likert type scale, and
then categorized into “significant” or “insignificant” contribution. The
“significant” category is composed of responses with which the re­
spondents described their “contribution” as “a lot,” “substantial,”
“important” or “very important.” In the “insignificant” category, the
respondents stated their contribution as “little,” “no” or “I do not know.”
Accordingly, in half of the responses, the participants considered their
“contribution” to the management of medical errors as ‘insignificant.’
For instance, a surgical patient replied to the above question as, “… I
have no role to play in it.” When probed why, he said, “Because, it is the
result of mistakes committed by the health professionals. Only they know
about it, including its treatment…”
The participants were also asked, “How important is a precise
description of your illness for the proper diagnose and treatment?” to
explore their understanding of the contribution of a proper description
of illnesses to medical error prevention and control. Their responses to
this question were a binary measure of “contributes” or “does not
contribute.” Seven of the 12 responses fell under the “does not
contribute” category. A patient in this category said, “… The care pro­
viders touched me, took and examined blood, urine… samples to determine
my illness. I do not think that what I tell them about my illness would impact
my diagnoses or treatment.” Similarly, another patient said, “… I do not
think that the story I tell about my illness can affect my diagnosis or
treatment…”
In the end, the participants were asked about their level of involve­
ment in the care process. The subsequent responses were dichotomized
into “active” or “passive” involvement categories: those responses that
indicated the involvement of responders in the shared decision-making
process were assigned to the active category, and otherwise to the pas­
sive. Accordingly, 11 of the 12 responses belonged to the latter category.
One participant stated, “The health professionals never involved me in the
planning or implementation of my treatment. They only gave me orders
saying do this or that, take this or that medicine… I have been here for a
while. I underwent surgery twice. They did not inform me that I was about to
undergo surgery for the second time. I can hear English. … I heard a physician
telling his students… that another surgery was imminent. They did not tell me
why I had to undergo surgery for the second time. What they told me was not
to eat and drink until the next morning.”
It was, though, apparent that many of the study participants were
confused by the question. A 35-year old cancer patient, for example,
replied to the above question, saying, “They consulted me very well in
every procedure they do on me.” However, when questioned further about
whether the health professional told him about diagnostic and thera­
peutic options or his right to refuse treatment, he stated, “No, not in that
W. Alemu et al.
way. They told me to do something, and I did it… When I said they consulted
me, I did not mean that they involved me in the processes of planning or
executing my treatment but let me know their decision.” Another partici­
pant, who claimed to be actively involved in his care, reacted to a
probing question, saying, “… Not like that. They only told me that they
needed to take this or that sample or take this or that drug. I am just a patient.
They know the best treatment for me. I did whatever they told me to do…”
4. Discussion
This descriptive, exploratory study examined how well patients un­
derstand healthcare quality, medical errors, and their role in the man­
agement of errors. Based on our findings, patients had an adequate
understanding of quality, which were similar to those reported by WHO
(2009) and much of the developed world (European Patient Forum,
2017). Participant responses showed the importance of healthcare
quality, as all the participants used it as a criterion for choosing a
hospital.
The quality of healthcare is often measured through measuring pa­
tient satisfaction with their care (Grøndahl et al., 2018; WHO, 2018). We
found that over half of our study participants reported that they were
dissatisfied with the quality of care they received. Our finding is similar
to that reported by the Lancet and others on global health care access
and quality, in which Ethiopia scored as one of the lowest (28.1 out of
1000) globally (Katuti, 2018; Lozano, 2018; Teshome et al., 2019).
We found that two-thirds of the study participants were aware of
medical errors, and three-fourths believed that medical errors occur in
the hospital in which they were receiving care. Likewise, over half of the
participants believed that medical errors happen to patients, and most of
them believed that the consequences of such errors could be very severe,
a finding that was also reported in Nigeria (Ushie et al., 2013). These
beliefs held by our study participants could very well contribute to pa­
tient dissatisfaction with the quality of care, since it is widely known
that medical errors undermine quality of care (Jha et al., 2013; Kobewka
et al., 2017; RiskAnalytica, 2017; WHO, 2017). High levels of patient
dissatisfaction can result in the avoidance of modern health care services
(Bazie and Adimassie, 2017; Birhane et al., 2011; Wellay et al., 2018;
WHO, 2018), which leads to poor health outcomes, quality of life and
productivity (Bazie and Adimassie, 2017; Birhane et al., 2011; Wilde-
Larsson and Larsson, 2008; WHO, 2018).
The proper management of medical errors is one of the most effective
strategies for enhancing the quality of care and patient satisfaction.
Patients play a major role in the proper management of such errors
(WHO, 2018, 2019). Nonetheless, the patients’ level of role is dependent
on their level of understanding their role (Britten, 2009; Karch, 2015;
Wilde-Larsson and Larsson, 2008) and involvement in the care process.
In this regard, we found that half of our participants believed they had
little or no part to play in the management of medical errors, and more
than half poorly understood the importance of properly describing ill­
nesses for the proper diagnoses and treatment. Thus, it appears as re­
ported by others that our participants could not identify their role in the
prevention of medical errors or mitigating the consequences of the
stated errors (Britten, 2009; European Patient’s Forum, 2017; Muhrer,
2014; WHO, 2016).
Patients contribute to quality of care when they are actively engaged
in the process. Active engagement provides patients with a better un­
derstanding of the etiology of medical errors (iSalus, 2018; Karch, 2015;
NHS England, 2018) and provides them with a mechanism to contribute
to error management (European Patient’s Forum, 2017; WHO, 2016).
These, in turn, allow patients to be instrumental in the attainment of
care quality (Davis et al., 2012; Harvard School of Public Health, 2014;
Institute for Safe Medication Practices, 2012; Karch, 2015; iSalus, 2018;
NHS England, 2018; Institute for Safe Medication Practices, 2012).
Allowing patients to be active participants in all aspects of the care
delivery process will result in high levels of patient satisfaction
(Grøndahl et al., 2018; Lozano, 2018; Siriwardena & Gillam, 2014) and
5
International Journal of Africa Nursing Sciences 14 (2021) 100278
improved care outcomes (Cornejo, 2018; iSalus, 2018; NHS England,
ND; Vahdat et al., 2014). Despite all these recommendations, we found
that the majority of patients were passive recipients of care, as they
lacked understanding of role and empowerment in the management of
errors.
4.1. Limitation of the study
This study has both limitations and strengths. The limitation of the
study included: first, that it was limited to one hospital in Addis Ababa,
Ethiopia, and findings might not be generalizable to patients in other
hospitals and other countries. Second, that it was conducted at only one
point in time, and there could be seasonal factors that might influence
patient responses. Third, that the study hospital was a referral facility
with patients diagnosed with chronic, severe, or complicated illnesses,
which could affect patient responses. Despite these limitations, we
believe that this study provides evidence that could be the foundation
for improvements in quality of healthcare and patient satisfaction in
hospitals in Addis Ababa, Ethiopian.
5. Conclusion
Although patients appear to comprehend the concept of healthcare
quality, they have not identified their role in achieving it. They have not
actively engaged in the care process either. Empowering patients and
actively engaging them in the care process can result in improved care
outcomes and increased patient satisfaction, both of which are beneficial
to patients, providers, and the health care system. Finally, we strongly
suggest further investigation of the possible causes of 1) the low level of
patient satisfaction, 2) the lack of patient awareness about their part in
attaining care quality, and 3) the absence of active involvement of pa­
tients in the caring process.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
We, the authors of this study, would like to thank the study partici­
pants for the study could not be realized without their participation. We
also are grateful to the hospital officials for allowing us to carry out the
study. Our warm gratitude goes to Dr Mirgisa Kaba (a professor of
qualitative study at College of Health Sciences, Addis Ababa University)
for his unreserved assistance on the analysis of the study, and Dr.
Cimiotti, Jeannie P. (a professor at Emory University) for editing the
paper for language use and grammar.
Authors’ contributions
All the three authors (Mr. Wudma Alemu, Dr. Eshetu Girma, and Mr.
Tefera Mulugeta) took part in conceiving, designing, conducting and
analyzing the study; writing up the report; developing and revising the
manuscript; and approving the final manuscript for submission.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ijans.2021.100278.
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