ARCHITECTURAL DESIGN AND PATIENT SAFETY IN HOSPITALS OF DEVELOPING COUNTRIES: A STRUCTURED NARRATIVE REVIEW OF OPEN ACCESS EVIDENCE

Abstract

Background: In all hospitals, care is associated with significant avoidable harm and there are estimated to be approximately two thirds of this avoidable harm in low and middle income countries. This risk is influenced by the architecture of hospitals, the spatial arrangement of the buildings, their water and hygiene system, and the facilities of clinical wards but there is no evidence from developing countries that has been collated. Objective: To conduct a systematic review of the available literature to synthesize open access evidence on the effect of architectural design features on patient safety in developing world hospitals, to assess the quality of the evidence, and to establish priorities for research that can inform evidence based design in the context of the hospital. Methods: Structured narrative review, based on the PRISMA 2020 transparency principles. In October 2026, searches were conducted in open access repositories, in journal platforms and in the portals of international agencies. Built environment characteristics in hospitals or health facilities in low or middle income countries were included, as were authoritative global reports, where they reported a safety-relevant outcome. Each source was checked against an independent record and certainty judged for each source. Results: Eight sources gave design specific evidence from developing country settings. Two studies in Peru demonstrated that natural ventilation was more effective than mechanical negative pressure rooms in terms of air change rate and that simple retrofitting to existing rooms increased ventilation by several-fold with a median 72% decrease in the modelled risk of tuberculosis transmission. The spacing in a South African outbreak investigation in a neonatal unit was documented at less than 1 meter and increased to 2 meters. Mostly low certainty findings were provided in the form of a consensus study from Haiti, a spatial analysis from Pakistan, and descriptive studies of noise and lighting. There was no evidence found which was peer reviewed for wayfinding, falls, medication errors, and maternity ward design. Conclusions: Evidence is strong for ventilation and weak in all other areas, and rarely measures patient outcomes. An evidence base for hospital design in developing countries requires multisite studies in diverse settings with measures which are common to all.