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Objective To assess the frequency and nature of adverse events to patients in selected hospitals in developing or transitional economies. Participants Convenience sample of 26 hospitals from which 15 548 patient records were randomly sampled. DesignMain outcome measures Two stage screening. Initial screening based on 18 explicit criteria. Records that screened positive were then reviewed by a senior physician for determination of adverse event, its preventability, and the resulting disability.Results Of the 15 548 records reviewed, 8.2% showed at least one adverse event, with a range of 2.5% to 18.4% per country. Of these events, 83% were judged to be preventable, while about 30% were associated with death of the patient. About 34% adverse events were from therapeutic errors in relatively non-complex clinical situations.Inadequate training and supervision of clinical staff or the failure to follow policies or protocols contributed to most events. ConclusionsUnsafe patient care represents a serious and considerable danger to patients in the hospitals that were studied, and hence should be a high priority public health problem. Many other developing and transitional economies will probably share similar rates of harm and similar contributory factors. The convenience sampling of hospitals might limit the interpretation of results, but the identified adverse event rates show an estimate that should stimulate and facilitate the urgent institution of appropriate remedial action and also to trigger more research. Prevention of these adverse events will be complex and involves improving basic clinical processes and does not simply depend on the provision of more resources. IntroductionPreventable harm to patients resulting from their healthcare is unacceptable at any time. Patient safety is first and foremost a clinical problem, but it is also an important cause of wasted resources. Keeping patients safe can also be viewed as a public health problem and a human rights issue.1 Documentation of the scale of iatrogenic harm to patients has been accelerating [3][4][5] and the focus moved from negligence to preventability. Results suggested that rates of adverse events in patients in hospital in the developed world were much higher than previously thought, with multiple studies showing rates of at least 8%. 6 Of these adverse events, more than 50% were judged to be preventable, and a worrying number of the patients experienced permanent disability or death as a result of the events. These reports suggest that the deaths of between 0.5% and 2% of patients in hospital are associated with an adverse event, which was often, but not always, preventable. These studies would rank harm from healthcare high on the list of all causes of death for the countries being studied. All published studies to date, however, have been from developed countries, with no reports from developing or transitional economies. This knowledge gap is a serious limitation to understanding the extent of the problem at the global level and, more imp...

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Sporadic reports from centres in the south and east of the Mediterranean have suggested that the prevalence of antibiotic resistance in this region appears to be considerable, yet pan-regional studies using comparable methodology have been lacking in the past. Susceptibility test results from invasive isolates of Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Enterococcus faecium and faecalis routinely recovered from clinical samples of blood and cerebrospinal fluid within participating laboratories situated in Algeria, Cyprus, Egypt, Jordan, Lebanon, Malta, Morocco, Tunisia and Turkey were collected as part of the ARMed project. Preliminary data from the first two years of the project showed the prevalence of penicillin non-susceptibility in S. pneumoniae to range from 0% (Malta) to 36% (Algeria) [median: 29%] whilst methicillin resistance in Staphylococcus aureus varied from 10% in Lebanon to 65% in Jordan [median: 43%]. Significant country specific resistance in E. coli was also seen, with 72% of isolates from Egyptian hospitals reported to be resistant to third generation cephalosporins and 40% non-susceptible to fluoroquinolones in Turkey. Vancomycin non-susceptibility was only reported in 0.9% of E. faecalis isolates from Turkey and in 3.8% of E. faecium isolates from Cyprus. The preliminary results from the ARMed project appear to support previous sporadic reports suggesting high antibiotic resistance in the Mediterranean region. They suggest that this is particularly the case in the eastern Mediterranean region where resistance in S. aureus and E. coli seems to be higher than that reported in the other countries of the Mediterranean.

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Summary Anecdotal data from the southern and eastern Mediterranean region suggests that self-medication with antibiotics is commonly practiced in many countries. In order to provide proper information on the situation, we undertook short structured interviews in out-patients clinics or primary health centres in Cyprus, Egypt, Jordan, Lebanon, Libya, Tunisia and Turkey. A total of 2109 interviews were undertaken of which 1705 completed the full questionnaire. Self-medication was reported by 19.1% (<0.1% in Cyprus to 37% in Lebanon) of respondents. Intended selfmedication ranged from 1.3% (95% CI 0%, 3%) in Cyprus to 70.7% (95% CI 64%, 77%) in Jordan. Upper respiratory tract symptoms were the most frequent reasons for which respondents indicated they would self-medicate. 48.4% of the whole group replied that they kept antibiotics at home, being highest in Lebanon (60%, 95% CI 51%, 69%). We found a significant association between antibiotic hoarders and intended users of antibiotics for self-medication. Our data confirms that non-prescribed antibiotic use is high within ambulatory care in southern and eastern Mediterranean countries, being almost twice that reported in a similar European study. Corrective efforts are * Corresponding author. clearly required in the region to ensure proper use of antimicrobials so as to reduce pressure for antimicrobial resistance.

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A total of 2,725 healthcare workers in 8 Mediterranean countries replied to a self-assessment questionnaire that assessed their perceptions on hand hygiene. Responses revealed that rates of hand hygiene compliance before patient contact were significantly less than rates after patient contact (P < .001) and that use of soap and water was preferred over use of alcohol-based hand rub. These findings suggest that self-protection could be a major subliminal driver for performance of hand hygiene.