Adverse Events in Healthcare Flashcards

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.