Patients can be harmed by, for example, transfusion errors, adverse drug events, wrong-site surgery, surgical injuries, preventable suicides, treatment-related infections, falls, burns or even mistaken identity. While adverse events are relatively rare, the majority of them are preventable. Does this mean that our healthcare systems are unsafe? Where do adverse events occur: is it only in hospitals? What is being done about this problem, and what can we do to improve the situation?
patient safety program in 2004 with the objective of improving safety and quality of care. To achieve high quality in healthcare systems, a patient must receive the treatment that gives the best health results based on the current state of scientific knowledge. While each healthcare professional has a different perception of what constitutes quality care, they all agree that responding to the patient’s needs by taking care of him or her in the “perfect” way is essential. Reaching this level of quality requires optimized procedures and processes to avoid preventable adverse events.
Solutions presented in this topic of the month
Can technology resolve all of the problems that cause high rates of adverse events? In fact, different solutions may be needed depending on the origin of the problem. Some institutions have implemented programs that address the problem at the organizational level. The WHO, in collaboration with experts, has created the Surgical Safety Checklist for use in the operating room. This checklist is a useful tool for confirming the identity of the patient, the procedure to be performed and the issues to be considered during the surgery. In this case, changing attitudes and communication procedures can reduce the number of preventable adverse events. And this raises the important question: Which is more efficient – using costly high technology that may require a difficult adaptation process for its users, or using low-cost innovations such as checklists?
This month, Hinnovic presents various issues related to adverse events, from the importance of improving quality in healthcare to the development of technologies and strategies aimed at limiting the number of preventable accidents. We also touch on the legal side with the presentation of an outline for a government no-fault compensation system.
An adverse event is a negative consequence of care that results in unintended injury or illness that may or may not have been preventable.
A preventable adverse event is an avoidable event in the particular set of circumstances.
An unpreventable adverse event is an adverse event resulting from a complication that cannot be prevented given the current state of knowledge.
An error is a failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim.
An active error is an error that occurs at the level of the frontline operator and whose effects are felt almost immediately.
A latent error is an error in design, organization, training or maintenance that leads to operator errors and whose effects typically lie dormant in the system for a lengthy period of time.
An accident is an unintentional and/or unexpected event or occurrence that may result in injury or death.
Author :Pauline Boinot, M.Sc.
Institute of Medicine (2000) To Err Is Human: Building a Safer Health System. Washington D.C., National Academy Press.
Runciman W., Hibbert P., Thomson R., Van Der Schaaf T., Sherman H., Lewalle P. (2009) Towards an international classification for patient safety: Key concepts and terms. International Journal for Quality in Health Care, 21(1): 18-26.