Improving patient safety through international partnerships: An ethnographic study


Patient safety is a global health priority. An established feature of health policy in high-income countries for over a decade, more recently attention has also turned to its importance in low-income countries. Improving patient safety in low-income countries is especially imperative given the vulnerability of populations, the need to avoid wasting limited resources, and the potential for strengthening health systems. Yet research into patient safety in low-income countries is limited, and little is known about the extent to which patient safety interventions developed in high-income contexts are transferable to resource-poor settings.

One strategy for promoting patient safety globally is that of international partnership. In its most characteristic form, international partnerships in this context involve hospitals in low- and high-income countries pairing up to work together, to improve safety.

International partnerships promise valuable benefits. However, such partnerships often span significant power asymmetries and divergent social, cultural and professional health contexts. There is limited research into how international healthcare partnerships may be optimised to support improvements in patient safety and the potential for learning on both sides of the partnership.

The research study

The study comprised longitudinal ethnographic case studies of two international patient safety partnerships in action. Each partnership comprised a pair of hospitals – one English hospital and one from an African country. Both pairs were participants in the World Health Organization’s African Partnerships for Patient Safety programme (APPS). The case studies involved interviews with APPS partners and staff from all four hospitals, collation and analysis of documentary materials, and extensive ethnographic fieldwork in the partner hospitals.

Project aims

The study aimed to strengthen the evidence-base for effective patient safety interventions in low-income countries and for optimising partnership-based approaches to intervention, including optimising the potential for reciprocal learning and mutual benefit between partners.

Research team

Emma-Louise (Emmilie) Aveling
Mary Dixon-Woods Peter McCulloch (University of Oxford)           
Yvette Kayonga (Catholic University of Rwanda) Ansha Nega (Gondar University)


Aveling E, McCulloch P, Dixon-Woods M. A qualitative study comparing experiences of the surgical safety checklist in hospitals in high- and low-income countries. BMJ Open 2013; 3(8)

Aveling EL, Kayonga Y, Nega A, Dixon-Woods M. Why is patient safety so hard in low-income countries? A qualitative study of health workers’ views in two African countries. Globalization and Health. 11:6

Aveling EL, Parker M, Dixon-Woods M. What is the role of individual accountability in patient safety? A multi-site ethnographic study. Sociol Health Illn. 2015 Nov 4. [Epub ahead of print]

Aveling EL, Dixon-Woods M, McCulloch P, Kayonga Y, Nega A Optimising Surgical Safety Checklist implementation: Key lessons for practitioners and partners University of Leicester 2016 Jan


Surgical Safety Checklist is no magic bullet to prevent unsafe surgery, say researchers Wellcome Trust news summary, pub. 2013 Aug 28

Hospital checklists are meant to save lives – so why do they often fail? Anthes E, Nature 523(7562) 2015 July 28

BBC World Service. Healthcheck. August 2015


College of Surgeons of East Central and Southern Africa AGM (Addis Ababa, Ethiopia), “It depends on the willingness of surgeons”: A comparative study of Surgical Safety Checklist Implementation in UK and African hospitals. Aveling E, Dixon-Woods M, McCulloch P. Dec 2012.

Centre for Infection Management Prevention Imperial College (London, UK), Invited Speaker, “I don’t have a sterile gown and you ask me to fill the checklist?” Implementing the WHO Safer Surgery Checklist in an African hospital: An ethnographic study. Aveling E. May 2012

UK Symposium on Partnerships for Patient Safety (Manchester, UK), Invited Speaker, “We have bigger problems than the checklist”: Improving surgical safety in UK and African settings, Aveling E, Feb 2013

Consortium of Universities for Global Health Annual Conference (Boston, USA): Replicating success: An ecological approach to understanding healthcare improvement interventions, Aveling E, March 2015


Collaboration with Dr Margareth Portela [Senior Researcher, Department of Health Administration and Planning] at the National School of Public Health, Oswaldo Cruz Foundation, Brazil, on the following project: Development and evaluation of a strategy to implement the WHO Surgical Safety Checklist, funded by Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPq. This collaboration is supported by a Special Visiting Researcher Grant, including a fellowship held by Emmilie Aveling, through the Programa Ciência sem Fronteiras [Science without Borders Program], funded by the Brazilian government. This collaboration also involves Hospital Universitario Onofre Lopes.

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