Adverse Events in Healthcare Flashcards

Study Notes

Adverse Events in Healthcare

An adverse event is an unintended occurrence resulting from clinical care that leads to patient harm.

Examples of Adverse Events

Wrong site surgery: Performing a procedure on the incorrect location.
Medication errors: Mistakes in prescribing, dispensing, or administering medications.
Pressure ulcers: Skin injuries resulting from prolonged pressure on the skin.
Wrong diagnosis: Incorrect identification of a patient’s condition.
Failure to treat: Lack of appropriate intervention for a diagnosed condition.
Patient falls: Incidents where patients fall, typically in healthcare settings.
Healthcare-associated infections (HAIs): Infections acquired during the course of receiving treatment in a healthcare facility.

Consequences of Adverse Events

Approximately 850,000 incidents occur within the hospital sector.
Direct costs of adverse events total around £2 billion due to additional hospital days required.

Limitations of Mortality Rates

Mortality rates carry a flawed concept for assessing quality.
Rates are influenced by non-hospital care factors, leading to data variability.
The choice of case mix adjustment models affects perceived outcomes.
No clear relationship has been established between mortality rates and quality of care.

Causes of Adverse Events

Latent failures stem from management decisions and organizational processes.
Work conditions, including workload, supervision, communication, and knowledge, contribute to adverse event risks.
Active failures encompass unsafe acts resulting from omissions, cognitive lapses, or rule violations.

Swiss Cheese Model

The Swiss cheese model illustrates that multiple factors can contribute to mistakes, emphasizing the complex nature of healthcare errors.

Active Failures

Active failures are unsafe acts committed by healthcare providers directly involved with patients, categorized into:
- Errors
- Knowledge-based errors: Inadequate understanding, e.g., junior staff working beyond their competence.
- Rules-based errors: Adhering to rules but causing harm, e.g., inappropriate medication dosages based on age.
- Violations: Conscious disregard for rules, often influenced by situational demands or a belief that it serves the patient’s best interest.

Understanding Latent Factors

Latent failures can remain hidden over time, stemming from working conditions, staff training, and socio-cultural influences.

Human Factor Approach

Emphasizes the role of human fallibility and inevitability of error in patient safety.
Focuses on designing workplace systems to reduce the probability of errors and mitigate their consequences.

Human Factor Approach Example

Surgical checklists have been proven to reduce surgical mortality rates by one-third when implemented.

Ideal NHS Organization Characteristics

Organizations should foster a safety culture by:
- Promoting hand hygiene.
- Reducing inpatient falls and pressure ulcers.
- Preventing venous thromboembolism.
- Optimizing pre-operative checklists usage.
- Utilizing real-time ultrasound for central line placement.

Response to Incidents

In the event of an incident:
- Report the occurrence.
- Assess the seriousness of the situation.
- Analyze the causes behind the incident.
- Maintain openness with affected patients, including apologies (Duty of Candour).
- Implement learnings to prevent future occurrences.

Description

This quiz consists of flashcards covering key concepts related to adverse events in healthcare. It includes definitions, examples, and consequences of unintended harmful events resulting from clinical care. Enhance your knowledge of patient safety and improve clinical practices.