Exploring the Environmental Health Implications of Invisible, Unnoticeable, and Overlooked Mistakes in Hospital Design: A Study in Egypt

Hospital Planning and design can have a significant impact on environmental health, and even seemingly minor mistakes or oversights can contribute to negative health outcomes for patients and hospital staff. This paper examines the impact of invisible, unnoticeable, and overlooked mistakes in hospital design on environmental health in Egypt, with a focus on identifying the risks associated with these mistakes and exploring strategies for mitigating negative outcomes. Through a review of the literature, this paper identifies several key environmental factors that can contribute to negative health outcomes in hospitals, including poor air quality, inadequate ventilation, noise pollution, infection, poor materials quality, inadequate lighting and any other factors could harm the hospital occupants. Additionally, this paper examines the impact of these factors on patient outcomes, including length of stay, recovery time, and overall health and well-being. Finally, this paper explores and studies these mistakes which are considered a frequent phenomenon in a large number of hospitals in Egypt to determine these environmental health risks. Overall, this paper highlights the importance of considering even the smallest details in hospital design, and offers recommendations for promoting healthy and safe hospital environments in Egypt.


Introduction
Healthcare buildings come under the category of essential services, and complex, and they are operational 24/7/365.As a result, hospital planning and designing (HPD) play a critical role in environmental health such as patient outcomes and the health and safety of hospital staff.The HPD procedures should not only follow the international guidelines and Egyptian code but also need knowledge, high expertise and specialized studies to achieve highly efficient design [1].It is known that the HPD must achieve and take into account an essential element, for example, but not limited, Easy access to the hospital building [2,3], functions of each department, and the relationships of departments with each other [4], ease of movement and circulation, way finding, sustainability, infection prevention, and control, quality, ease of cleaning and waste disposal [5], and time reduction in cases of threatening the patient's life, etc.And also achieve Ulrich's theory [6], related to the healing environment's elements, the most important of which are privacy, family support for the patient, noise reduction, water quality, air quality, and everything related to the positive distraction for patient wellbeing and hospital' staff satisfaction [3].The design staff may receive thanks and 1283 (2024) 012007 IOP Publishing doi:10.1088/1755-1315/1283/1/012007 2 praise from others, including the owner of the hospital, without knowing, for example, that the colours inside the hospital are black and white or brown without paying attention that these colours may psychologically harm the patient and increase his suffering.
In Egypt, the invisible, unnoticeable, and overlooked mistakes (IUOM) in the HPD process are a seemingly intractable problem and an ongoing threat to hospital occupants and by extension the environmental health.The author classifies these IUOMs into three categories: 1) Mistakes that no one pays attention to as long as the work is going in the hospital in one way or another.2) Mistakes that planners and designers consider not mistakes due to lack of knowledge and experience.3) Mistakes are not seriously taken into account by the design team.Modifying the majority of these IUOMs may need building rehabilitation or removing and rebuilding, and this will not happen due to the huge cost.IUOM are often caused (but are not limited to): a) Patient fall [7][8][9][10], for this case medical intervention is made to diagnose the cause of the fall and treat its effects, and the cause of the fall is not treated from the design point of view.b) If a patient or any person is infected due to respiratory infection [11][12][13], diagnostic and treatment procedures are intervened and the cause of transmission is not diagnosed and treated.c) If the patient is exposed to psychological and nervous pressure (patient stress) [6,14,15], no one may pay attention to him or the reason for this stress, and his health condition may worsen.Also, these mistakes are depriving the patient of his privacy, the discomfort of the hospital, and the large number of medical errors.
Here, we can say that these IUOM in HPD process may create high risks and will become a permanent and continuous source of negative return on patients and environmental health and consequently on the health sector in Egypt and will constitute a burden on the state budget.This paper aimed proposes recommendations to avoid these mistakes in the future to raise the level of healthcare in the health sector in Egypt.

Literature Review:
The objective of the literature review conducted in this study is to demonstrate the risks of poor HPD on environmental health and to review the literature and guidelines that organizes and supports the consideration of all aspects of environmental health in the design process, with a view to fostering a positive impact on both environmental health and the healthcare sector in Egypt, as follows: 1-Guidelines for the successful HPD [2][3][4] presents a scientific approach to HPD.The guidelines outlined in the article are based on empirical evidence and research studies, providing a comprehensive framework for the successful HPD.The article emphasizes the importance of considering the needs of patients, healthcare providers and staff, and the community in the planning and design process.Through the implementation of these guidelines, hospitals can optimize their layout, functionality, and efficiency, ultimately improving patient outcomes and the overall quality of care provided.2-HPD procedures requires a detailed and thorough approach to ensure that the facility meets the needs of patients, staff, and visitors.The first step in the planning process is to conduct a needs assessment to determine the size and scope of the facility.Once the needs have been identified, the strategic planner and the team of architects and designers can begin to create a conceptual design that includes the layout, size, and functionality of each space within the hospital.This design will then be refined and finalized based on input from stakeholders, including medical professionals, patients, and community members.Throughout the process, it is important to 3 consider factors such as accessibility, safety, and infection control to ensure that the hospital is a safe and welcoming environment for all who enter its doors [16].3-In HPD, the selection of appropriate flooring material and finishes is of paramount importance to prevent patient falls and minimize the spread of infectious diseases [8][9][10].The flooring material should be slip-resistant and provide adequate traction to minimize the risk of falls.Additionally, the finishes should be easy to clean and disinfect to prevent the spread of infectious agents.These measures are crucial in maintaining a safe and hygienic healthcare environment, which is essential for promoting patient well-being and reducing the risk of hospital-acquired infections.4-This article presents an overview of the constituent elements of the healing environment in the context of hospital planning and design and aims to provide a comprehensive assessment of the factors that contribute to the creation of a healing environment and their incorporation in the design progression of healthcare facilities [14].5-A prompt form has been developed to swiftly inspect and authenticate HPD endeavours in compliance with present regulations, in order to minimize the reliance on specialized and highly skilled personnel.This form generates a comprehensive report that includes the regulations that were verified, as well as the record of alerts and shortcomings in regulation implementation [1].6-The optimal HPD with a healing environment, with regards to minimizing distractions, promoting a sense of control, and providing social support, should align with the cultural norms of both patients and staff in Egypt.but that design cannot be a one-size-fits-all process [17].7-To ensure optimal quality in HPD, it is imperative to involve shared decision-making in the design process, incorporating knowledge and experiences, as suggested by reference [18].8-The achievement of an ideal and sustainable hospital design is greatly impacted by the expertise of the hospital planner and their design team, as well as the healthcare system, hospital management system, the organization of the healthcare system, and the Healthcare Policy.Moreover, it is important to consider the environmental health aspect in the hospital design to reduce the negative impact on the environment and the health of the patients and staff.The use of sustainable materials, water and energy conservation, and waste management practices should be incorporated into the HPD to promote a healthier and greener environment [19].9-Inadequate circulations in (HPD) can have contrary effects on the health and well-being of patients, staff, and visitors.Some of the negative impacts include increased stress levels, anxiety, difficulty finding one's way, disorientation, reduced cognitive function, and frustration associated with limited access to nature.Conversely, a well-designed patient circulation system that is based on evidence-based movements can improve the environmental Health of hospitals [5].10-This study examines the impact of several environmental health and design factors on patient safety in healthcare settings.Specifically, air excellence, lighting, patient room strategy, patient transfers, interior design elements, nosocomial infections, and medical errors are analyzed.
Additionally, the study explores how issues pertaining to staff comfort and satisfaction, including noise levels and unit design layout, can contribute to staff fatigue, stress, annoyance, and burnout, potentially leading to adverse events within the hospital setting [7].11-Single patient rooms have become increasingly popular in the healthcare industry due to their numerous benefits such as: Enhance privacy, reduce infections, improve patient recovery, increase patient and staff satisfaction, better communication and Increase safety.Overall, single patient rooms offer many benefits for patients and healthcare providers, and they are becoming increasingly popular in the healthcare industry as a result [20].
12-The physical environment of a hospital plays a crucial role in the overall well-being of patients, staff, and visitors.In the 21st century, hospitals are recognizing the importance of creating a healing environment that promotes the physical, emotional, and spiritual health of patients.This includes designing spaces that are calming, comfortable, and aesthetically pleasing, as well as incorporating natural light, views of nature, and artwork.The physical environment also plays a role in reducing the risk of infection and promoting safety.Hospitals of the 21st century are embracing innovative design concepts and technologies to create healing environments that support the delivery of high-quality healthcare services [15].13-Healing environment factors have a significant impact on patient well-being and staff satisfaction.Studies have shown that factors such as natural lighting, comfortable temperature, and access to nature can improve patient outcomes, including reduced stress and anxiety, faster recovery times, and increased satisfaction with care.Additionally, a healing environment can also positively impact staff satisfaction, leading to improved job performance and reduced burnout.Overall, creating a healing environment that prioritizes patient and staff needs can lead to better health outcomes and a more positive healthcare experience for everyone involved [15,21].14-HPD may improve patient safety, reducing nosocomial infections, patient falls, medication errors, staff stress, and other issues related to patient safety.In contrast, the optimal HPD is considered a barrier to adverse events in hospitals [7].15-The implementation of supportive design in healthcare facilities has been observed to have a beneficial effect on the well-being of patients, as well as the job satisfaction of staff.This can be achieved through several measures, including optimizing interior design to promote wellness, providing staff areas conducive to high productivity and efficiency, and addressing factors that contribute to stress reduction, Ulrich's theory [6].16-The phenomenon of chromo-therapy, which involves the use of colours to manipulate the human brain and behaviour, has emerged as a prominent alternative medicinal practice Historically, this therapeutic approach has been extensively employed in various cultures, including Egypt, India, and China, for several centuries [22].17-Patient safety relevant to the medical issues, was identified as a main factor of improving the health care provision.Patient safety affected by level of education, professional category, participation in a patient safety program, reporting of adverse events, organizational learning, physical space environment.Enhancing patient safety culture is deeply required to reduce the medical errors [23].18-Infection Control Risk Assessment and Preventive Measures Toolkit for Hospitals Construction, Renovation, and Maintenance (ICRA), provides essential guidelines for managing infection risks during hospital construction, renovation, and maintenance.It is a comprehensive resource that outlines preventive measures and risk assessment strategies, ensuring that hospitals maintain a safe and healthy environment for patients, staff, and visitors [11].19-Based on the cited reference [24], it has been observed that patient safety is at risk due to medical errors caused by nurses.However, it is noteworthy that cited source does not account for the potential occurrence of such errors resulting from the presence of Invisible, Unnoticeable, and Overlooked Mistakes in HPD.20-Heating, ventilation, and air conditioning (HVAC) requirements are critical considerations in hospital planning and design.Hospitals are unique buildings that require specific temperature, humidity, positive and negative pressures, and air quality standards to ensure the safety and well-being of patients, staff, and visitors.Failure to meet these standards can result in the spread of infectious diseases, allergies, respiratory problems, and other health-related issues [25].21-The lack of proper mechanical ventilation and limited access to hospital departments can have a significant impact on the spread of influenza.Poor ventilation systems can lead to the accumulation of airborne viruses and bacteria, increasing the risk of infection for both patients and healthcare workers.Additionally, limited access to hospital departments can prevent individuals from receiving timely medical care, exacerbating the severity of their illness.Therefore, it is crucial to prioritize measures that improve ventilation and provide adequate access to hospital facilities to reduce the impact of influenza outbreaks [26].22-When it comes to maintaining a safe and healthy environment, there are many factors to consider.Ventilation is crucial for ensuring that fresh air circulates throughout a space, while special air handling is necessary for preventing the spread of airborne infections.Protective environments must also be established for individuals with weakened immune systems.Water quality is another important consideration; as contaminated water can lead to a variety of health issues.Proper waste disposal is essential for preventing the spread of infection, and precautions must be taken to prevent both airborne and contact transmission of pathogens.By addressing these various factors, we can create a safer and healthier environment for all [27].23-The potential hazard associated with inadequate air quality in hospital settings has been documented in literature [25,28,29].24-The National Accreditation Board for Hospitals and Healthcare (NABH) focuses primarily on operational aspects related to healthcare.This includes assessing access to healthcare services, ensuring continuity of care for patients, managing medication administration, protecting patient rights and promoting patient education, preventing and controlling hospital infections, ensuring patient safety, promoting quality improvement, managing overall facility operations and safety, managing human resources, implementing information management systems, and creating checklists for key performance indicators and medical errors [13].25-The scope of this manual is centred on the operational protocols of hospitals to acquire accreditation, which encompasses patient safety, infection control, medical management, patient rights, and organizational workflow within the healthcare delivery system [12].However, this handbook overlooks the dimensions of environmental health in the perspective of hospital planning and design.26-The construction and renovation of the new hospital's building should take into account the principles of infection prevention and control.This includes, but is not limited to, conducting an infection control risk assessment, installing hand wash stations, ensuring proper cleaning of environmental surfaces, and optimizing circulation within the hospital.Furthermore, when designing the single-patient rooms, the selection of materials for flooring, walls, counters, and other surfaces should be carefully considered, along with the quality of medical and office furniture.These measures are essential to ensuring the safety and well-being of patients and healthcare workers within the hospital setting, and should therefore be given high priority in the hospital's HPD [20,30].27-The enhancement of safety culture, mitigation of fatigue and stress-related medical errors, and reduction of potential medical errors are critical factors that contribute to improving healthcare quality and ensuring patient safety, as previously noted [31].28-It is necessary to implement essential interventions aimed at fostering and improving the culture of patient safety in order to mitigate errors that may arise within the healthcare environment [32].
29-Enhancing the hospital design team's culture of patient safety such as but not limited to, noise reduction, scalability, adaptability, flexibility, visibility of patients to staff, automation where possible, minimizing fatigue, immediate accessibility of information close to the point of service, Operative/post-op complications/infections.Also, all events relating to medication errors, inpatient suicides, transfusion-related events, Patient falls, deaths related to surgery at the wrong site, and medical equipment hazards [33].

Methodology:
The author used a qualitative method (case study approach) that allows for diverse, flexible and more subjective interpretations in their findings and interpretation.The author's experience (In hospitals strategic planning) and perspective have a direct impact on the interpretation of the findings and conclusions reached.This method relied on a site visit to 24 hospitals and medical centers were visited in 8 governorates in Egypt.The used method is to collect data as repetitive patterns of IUOM as a useful tool in showing how Risks it is to patients and hospital staff considering the literature review, to best serve the objectives of the study.

Study Criteria:
When considering hospital design from an environmental health perspective, several criteria are recommended to ensure a safe and healthy environment for patients, staff, and visitors.To investigate IUOM, the author put in consideration the following 13 key elements relevant to planning and design to assess and measure the risks of these mistakes and determine the extent to which they achieved the governmental local code and international standards.In addition, its negative impact on hospital occupants and the level of healthcare provision.
2-Life threating design' consideration, such as facilitation of the vertical and horizontal travel for patients and staff.
3-Infection prevention and control.
9-Route of heavy equipment entry.
12-Other aspects of healing environment.
13-Quality of medical equipment and medical furniture in terms of Infection Control Risk.
Assessment (ICRA) rules and healing environment.Data were collected from 24 hospitals and medical centers in 8 governorates in Egypt.as shown in 'Figure 1'.The method relied 28 Repeated IUOM relevant to the HPD with respect to the reviewed literatures, the Author categorized the risks of the monitored 28 IUOM to moderate (M) and high (H) as shown in table 1.

Data analysis:
The study showed that the 28 Mistakes are not repeated in all the target sample, but there are repeated mistakes with a minimum of 6 hospitals and a maximum of 20 hospitals (column 3) as shown in table also showed that the ratio of high to moderate risk in the mistakes that were monitored is as follows: Whatever the accuracy of the IUOM' categories evaluation, the most important thing is to draw attention that a necessary action to be taken to avoid these mistakes in the future.

Results
The results of case study through visits to 24 hospital medical centres in 8 governorates in Egypt showed: a) 64.3% from 28 monitored mistakes measured as high risk and 35.7% moderate risk as shown in 'Figure 2'   c) The monitored Mistakes sample are not repeated in all the targeted sample, found the repetition rate was varied between 25% to 83.3 % as shown in 'Figure 4'.

Summary
Hospital building are extremely the main core for efficient and functioning healthcare systems, therefore the HPD should be is a very meticulous process, and requires a design team, headed by a hospital strategic planner at a high level of knowledge and experience relevant to all details of hospitals in order to reach an ideal design to create a building that meets the requirements of health care covered by patient comfort, staff satisfaction, free of any adverse events to create a safe environmental health.
In Egypt, we noticed a great acceleration in the design and establishment of hospitals for public and private sectors to face the steady increasing in population and reach the full realization of the comprehensive health insurance system for all Egyptians.Unfortunately, the design process of the hospital faces many challenges the most important of which is that the design process may be awarded to an unqualified team which leads to the creation of IUOM with its negative impact on: 1) patient safety, security, privacy and wellbeing.2) Healthcare providers concerning quality of services, medical errors, satisfaction and wellbeing.3) Visitors in terms of Stress, satisfaction and fear.4) Hospital' building quality, medical and paramedical services, sustainability and expandability.5) Hospital Owner regarding the reputation, legal issues and annual income.6) Healthcare sector concerning healthcare level, annual budget effectiveness, health culture and wellbeing, as illustrated in 'Figure 5'.It is recommended to prevent the IUOM from the repetition and stopping this phenomenon, otherwise we will continue to rotate in a cycle that is difficult to get out of, which will negatively affect patients, especially the culture related to the environment of health care and its inheritance to children and grandchildren, thus creating generations with low cultures relevant to the environmental health and consequently preventing generations from developing with regard to health care.The author believes that avoiding the errors that have been observed not only for patients and health care providers, but also to raise the cultural level of at least 50% of Egyptians.
This work suggests a shared-decision making to improve HPD process and reduce the IUOM by treatment the reasons, by taking in account the author recommendations which will support for creating high quality healthcare environments.

Discussion
Referring to the results of method in this work (Visits to 24 hospital medical centres) are showed that, 64.3% from 28 monitored IUOM measured as high risk and 35.7% moderate risk, the repetition of IUOM samples varied form 6 times to 20 times in 24 hospitals and the monitored IUOM samples are not repeated in all the target sample, found the repetition rate was varied between 25% to 83.3%.
From these results, we find the risk ratio of IUOM of both types is very high, especially with regard to hospitals, and its repetition warn that it is a phenomenon whose causes must be diagnosed and which relate to the design team, as the author sees it as follows: a) Lack of knowledge, experience and studies related to all the subtleties that occur within the hospital, only The design team seeks to achieve the requirements of the local code, and may have very poor knowledge relevant to the life-threatening design, such as but not limited: facilitating vertical and horizontal travel of patients, infection prevention and control, patient safety and security, privacy, way finding, healthcare technology and systems requirements, ethical and data security, heavy equipment entry route, Patient well-being, staff satisfaction and all other issues related to the Environmental health.b) Lack of consideration for multisensory experiences in HPD.c) Hidden dangers or errors in healthcare systems that go unnoticed.d) Inward-facing impacts on healthcare professionals' willingness to seek help or disclose mistakes health environment planning and design.e) Lack of patient safety culture among HPD team and some of healthcare professionals.f) Outsourcing or cost-cutting measures that prioritize financial considerations over environmental health and safety.g) Failure to properly identify potential sources of failures h) Lack of hiring a professional hospital planner in such projects.:

Conclusion
The hospital building holds significant importance within the healthcare industry, as its efficiency and safety directly impact the healthcare process and environmental health.However, the IUOM in HPD for new construction projects or renovations often becomes a challenging arena fraught with potential problems.These mistakes pose a high risk to patients, healthcare providers, and visitors, resulting in a negative impact on the healthcare sector in Egypt.Unfortunately, these mistakes are often discovered after construction, leaving hospital staff and patients compelled to work within an imperfect environment, necessitating costly rectifications.
Analysis of collected mistakes from targeted samples reveals a shortage of knowledge and expertise within the design team, demanding immediate action.In response to the persistent challenge of HPD errors, policymakers and practitioners must establish comprehensive rules and guidelines to foster improvement.Gradual development of guidelines and rules over the years is no longer sufficient.Promoting a culture of safety requires proactive interventions that empower, enact, and elaborate upon it, aligning with the existing culture.
This paper presents essential recommendations to prevent future mistakes, emphasizing the crucial role of decision-makers in the Ministry of Health and the political administration of Egypt, who must demonstrate the necessary political will to implement these recommendations.By doing so, we can effectively reduce hospitals errors and ultimately save lives.

Recommendations
a) Ensure that all healthcare professionals involved in healthcare facility planning and design (HPD) possess the necessary knowledge, training, and expertise to make informed decisions and identify potential risks and hazards.Provide continuous education and professional development opportunities to support ongoing learning and improvement.b) Incorporate principles of multisensory design into the Egyptian Code, taking into account the healing environment, environmental health, and enhancing the overall patient experience.c) Implement robust quality control processes and conduct regular audits to proactively identify and address potential issues before they escalate into significant problems.d) Establish policies and procedures that foster open communication, transparency, and a culture of learning from mistakes.e) Promote a culture of safety and accountability among all healthcare professionals involved in healthcare facility planning and design, as well as healthcare providers, through academic subjects and continuous training programs.f) Prioritize environmental health and safety considerations in the decision-making processes and allocate sufficient resources to ensure safe and healthy hospital environments and preserve environmental well-being.g) Conduct comprehensive risk assessments during the planning and design phase, involving multidisciplinary teams comprising healthcare professionals, architects, and engineers.h) Include identified mistakes in the Egyptian Code under the section titled "Mistakes to be avoided."These mistakes should be thoroughly inspected during the hospital design review process for approval (accreditation) by the Ministry of Health.i) Establish regulations and guidelines for consulting offices that mandate the involvement of strategic professional planners in the healthcare facility planning and design of HPD process.j) Develop a comprehensive checklist for approval and inspection from a planning and design perspective to ensure adherence to the necessary standards and requirements.

Figure 2 -
Figure 2-Risks of the targeted samples.b)The repetition of Each mistake of IUOM varied form 6 times/hospital to 20 times/hospital in targeted 24 hospitals as shown in 'figure3'.

Figure 3 -
Figure 3-Repeated mistakes in the targeted sample

Figure 4 -
Figure 4-Minimum and maximum repetition of monitored mistakes

Table 1 -
IUOM and the related risks S.N.

Table 2 -
IUOM and risks percentage