Adverse Events in Health Care

I have selected “Adverse Events in Health Care” as a topic for this assignment as I started working on it during the Canadian Patient Safety Institute designated “Canadian Patient Safety Week (Oct 28-Nov 1, 2019)”.

I have worked in health care for the past 25 years and have seen firsthand the evolution of patient safety.  I have seen the damage that can be done to the patient, the health care providers and the system as a whole when an adverse event occurs.  At the very least an adverse event can lead to patient’s loss of confidence, a health care provider’s psychological trauma and/or a health care system’s image being compromised; at the very worst it can lead to death and criminal charges. 

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Adverse events in health care are unexpected, and for the most part, preventable outcomes that happen during the delivery of care either by omission ( e.g. forgetting to put rails on the bed of an elderly person) or commission (e.g medication dosage error)(1) . Historically the blame and shame was on the inattention or poor judgement of the individual health care provider.  While this individual blame is still prevalent, great work is being done within the health care system to create reporting environments that support rather than blame.  Supporting instead of blaming health care providers throughout an event enables the system to learn from and avoid future events “... experts suggest that the greatest gains in improving patient safety will come from modifying the work environment of health care professionals, creating better defences for averting adverse events and mitigating their effects.(2) 

According to the Canadian Adverse Events Study (CAES) published in May 2004 (2) 7.5% of all hospitalizations in Canada had an adverse event that harmed patients.  According to CPSI 2019 Annual Report (3) “..in terms of mortality, patient safety ranks third behind cancer and heart disease.” Not only do these numbers negatively impact the patient, and as second victims (4) the health care providers involved, it also leads to longer hospital stays and therefore increased health care costs. “…patient safety incidents will cost the health care system $82 billion”. (5)

In 2002, a report from National Steering Committee on Patient Safety (Building a Safer System) (6) highlighted patient safety issues in Canada.  Recommendations from this led to the federal government creating the Canadian Patient Safety Institute (CSPI).  The CSPI is tasked with providing awareness and support for organizations in their patient safety improvement measures.  In 2004 Canada’s first national adverse events study was released “The Canadian Adverse Events Study: the incidence of adverse events among hospitals in Canada”.(2) This study highlighted patient safety issues at the local and national level and marked a turning point for Canada’s health care organizations.  No longer was this an “individual” issue, this was an issue the whole health care system must get behind to come up with solutions aimed at reducing these preventable events.

Through media campaigns and health care organizational policy changes there was a new focus on quality improvement and patient safety.  Reading through the history of Accreditation Canada’s website, it was in 2008-2009 that new quality standards and required organizational practices were introduced through the newly launched Qmentum Program with a focus in areas such as restricting the use of dangerous abbreviations, heparin safety, narcotic safety, hand hygiene audit, pressure ulcer prevention and suicide prevention. (7) In 2010 the Canadian Institute for Health Information (CIHI) launched a national system for incident reporting to report on and analyse medication incidents in health care organizations across Canada. (8)

Since 2011, CIHI and CPSI have begun working together to coordinate measurement tools and reporting practices. Through this relationship, there is the ability to use combined sources of data/information such as the discharge abstract database, (9) patient safety incident reports, patient experience surveys, and infection control data to find out what conditions in the system may have led to an adverse event.  This collaboration has led to a categorization list of 4 different types of adverse events; 1. Health Care/Medication Associated Conditions (37%), 2. HealthCare/Associated Infections 37%, 3. Procedure-Associated Conditions (23%), and 4. Patient Accidents (4%). (10)

Today, patient safety is a quality issue that is tied to an organization’s health care performance.  This performance is based on improved patient safety reporting and disclosure requirements.  Many articles discuss the need for a change in culture on reporting.   Near miss events are often times not reported because of fear and stigmatization of blame. An organization cannot change what it does not know. CPSI’S theme for 2019 is battling systemic silence.  CPSI wants to teach people that “.... if something looks wrong, feels wrong, or is wrong – we need to speak up.” (11) The article “Adverse Events in healthcare: learning from mistakes“ (12) refers to the Aviation industry as a place to go to learn how confidential reporting of near-misses provided that industry with a rich source of data.   While it is the end goal to prevent errors before they happen, it is just as important to document the occurrences so that the organization can learn from them.

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So have any of these collaborations, reports and analysis of the existing system led to any improvements in the current situation? From my perspective, Yes.  Organizations are now embedding reduction of adverse event strategies in all relevant policy and procedures. Quality teams are in place at accredited hospitals tasked with working on their ROPs, monitoring and contributing to the data and reporting these voluntarily.  The fear of disclosing an event to the patient is changing with many provinces adopting apology legislation which reduces the concerns about the legal implications of making an apology after an event has happened.  By shining a light on adverse events and its impact on the system as a whole, it becomes a normal course of business and creates a reporting environment that is conducive to learning. 

The collection of data on issues such as these is paramount to finding out where the problem lies.  Canada’s health care organizations gather this data from a variety of sources eg. reviewing patient charts, incident reporting information and interviewing staff and patients.  But data is just data and even now in some provinces reporting on these adverse events is voluntary.  If there are no universal standards of collection in place, then there is no ability to measure and analyse the data to monitor its effectiveness.

Data collection and creation of universal standards is the key in getting a handle on this trend.  As an HIM professional, we have an opportunity to advise organizations on where there are opportunities for improvements. (13) Data quality is one of our four domains of practice (14) and as such our work is to ensure that proper access to and the use of the statistical information needed to identify trends like adverse events are accurate and readily available to health care organizations. 

References

1. Rodziewicz TL, Hipskind JE. Medical Error Prevention. [Updated 2019 May 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Retrieved  from: https://www.ncbi.nlm.nih.gov/books/NBK499956/
2. Baker, G. R. (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170(11), 1678–1686. doi: 10.1503/cmaj.1040498
3. Advancing Patient Safety Right Now. (2019). Retrieved from https://annualreport.patientsafetyinstitute.ca/en/advancing-patient-safety-right-now.php
4. Wu, A. W. (2000). Medical error: the second victim. Bmj, 320(7237), 726–727. doi: 10.1136/bmj.320.7237.726
5. The Case for Investing in Patient Safety in Canada (2017). Retrieved from https://www.patientsafetyinstitute.ca/en/About/Documents/The%20Case%20for%20Investing%20in%20Patient%20Safety.pdf
6. National Steering Committee on Patient Safety. (2002). Building a safer system: A national integrated strategy for improving patient safety in Canadian health care. Retrieved from http://rcpsc.medical.org/publications/building_a_safer_system_e.pdf
7. Our History – Accreditation Canada.  Retrieved from https://accreditation.ca/intl-en/about/our-history/
8. National System for Incident Reporting (NSIR). (2019, October 22). Retrieved from https://www.cihi.ca/en/national-system-for-incident-reporting-nsir
9. Discharge Abstract Database metadata (DAD). (2019, November 15). Retrieved from https://www.cihi.ca/en/discharge-abstract-database-metadata.
10. Measuring Patient Harm in Canadian Hospitals, Oct 2016. Retrieved from https://secure.cihi.ca/free_products/cihi_cpsi_hospital_harm_en.pdf
11. Events: CPSI Communications Tool Kit for Healthcare Providers and Leaders. (2019). Retrieved November 16, 2019, from https://www.patientsafetyinstitute.ca/en/Events/cpsw/
12. Rafter, N., Hickey, A., Condell, S., Conroy, R., Oconnor, P., Vaughan, D., & Williams, D. (2014). Adverse events in healthcare: learning from mistakes. Qjm, 108(4), 273–277. doi: 10.1093/qjmed/hcu145
13. Abrams, K. J., & Gibson, C. J. (2013). Fundamentals of health information management. Ottawa, Ontario: Canadian Healthcare Association. (pg 54)
14. Thompson, V. D. (2020). Health and health care delivery in Canada. Toronto: Elsevier. (pg 320)