Dr Tracey McDonald AM PhD FACN, Professor of Ageing, 2014
Many of us are concerned about issues of patient safety and as Professor of Ageing I have a particular interest in the safety of older people who need to access effective health care services. The dilemma for some older people is whether it is safer to stay out of hospitals and try to manage your illnesses or injury conservatively - or to seek treatment in an environment that is laden with other risks and threats to your ongoing health and quality of life. This unacceptable situation is occurring globally and I am strongly of the view that nurses are at the centre of both the cause (sadly) and the solution to the problem. Our clinical nurses could act directly to ensure people are safe and that treatment is appropriate and effective; our nurse managers have opportunities to manage the organisational risks and set up systems that equip clinicians with the resources to practise proficiently; our nurse educators could ensure that skilled graduates emerge with an acute awareness of the risks of mediocre practice; and our nurse researchers could focus their analytical skills on finding out why mistakes and omissions occur, and what works in preventing adverse events. It is just a matter of focus and priorities – and the confidence in our professional autonomy to set those priorities for ourselves.
You may be interested to know that WHO Patient Safety has just released the results of the Latin American Study of Adverse Events (IBEAS). It is the result of a collaborative effort between the governments, the Pan-American Health Organization and WHO Patient Safety. In this snapshot of a given day, 1 in 10 patients admitted to the participating hospitals were suffering from, or undergoing treatment for, a health care-related adverse event. The risk of suffering adverse events doubled if the entire hospital stay was considered. This evidence is a reflection of the reality of many other hospitals in transitional countries across the globe and it highlights the importance of addressing patient safety globally. The IBEAS study is the first large scale study of this kind in Latin America. To access the study results in English: https://www.who.int/patientsafety/research/ibeas_report_en.pdf
When we look at the situation in Australia where around 20,000 patients die annually from hospital caused infections, trauma and conditions that they did not have when they were admitted - it is surprising to find that very little research is being conducted into this aspect of our health services' outcomes in which the legal fraternity has an acute interes. Further, the opportunity for international comparison research is limited because of the methodological diversity (and paucity) of information collected on health-care related adverse events. But a possibility now exists that this level of disorganisation could be resolved if the political will can be found.
In 2009 the WHO released the International Classification for Patient Safety (ICPS) to enable categorization of patient safety information using standardized sets of concepts with agreed definitions, preferred terms and the relationships between them being based on an explicit domain ontology (e.g., patient safety). The ICPS is designed to be a genuine convergence of international perceptions of the main issues related to patient safety. It is hoped that the framework will facilitate the description, comparison, measurement, monitoring, analysis and interpretation of information to improve patient care.
The conceptual framework for the ICPS was designed to provide a much needed method of organizing patient safety data and information so that it can be aggregated and analysed to:
More information on the ICPS can be found on: https://academic.oup.com/intqhc/article/21/1/2/1887721
The best information I can find on the Australian situation is a paper by Runciman et al (2003) Adverse drug events and medication errors in Australia, (Int J Qual Health Care (2003) 15 (suppl 1): i49-i59. doi: 10.1093/intqhc/mzg085). The abstract can be accessed at: http://intqhc.oxfordjournals.org/content/15/suppl_1/i49.short They report on their examination of systematic literature reviews and reports from data collections of the Australian Bureau of Statistics, Institute of Health and Welfare, Council for Health Care Standards and Patient Safety Foundation. At that time they believed that improved monitoring of these events was urgently needed.
Briefly, they found:
Results (medical record reviews): We have shown that 2–4% of all hospital admissions, and up to 30% for patients > 75 years of age, are medication-related; up to three-quarters are potentially preventable.
Results (routine data collections): Routine death certificate and hospital discharge data coded using the International Classification of Diseases capture less than half as many ADEs as medical record reviews. Of coded adverse events that contributed to death, 27% involved an ADE, as did 20% of adverse events identified at discharge and 43% at general practice encounters. There is a strong correlation between increases in medication use and rates of adverse drug reactions (ADRs) associated with hospitalization.
Results (drugs implicated): These were similar in all the above studies: anticoagulants, anti-inflammatory drugs, opioids, anti¬neoplastics, antihypertensives, antibiotics, cardiac glycosides, diuretics, hypoglycaemic agents, steroids, hypnotics, anticonvulsants, and antipsychotics.
Results (clinical indicators): An ADE is reported in 1% of hospital admissions, while some hospitals do not report ADRs to the national collection. Only three-quarters of patients with acute myocardial infarction receive thrombolytics within 1 hour of presentation. Five per cent of patients on warfarin record an international normalized ratio > 5, and 1%, 0.05%, and 0.2% ¬suffer abnormal bleeding, cerebral haemorrhage, or death, respectively.
Results (the Australian Incident Monitoring System): Twenty-six per cent of 27 000 hospital-related incidents were medication-related, as were 36% of 2000 anaesthesia-related incidents, and 50% of 2500 general practice incidents.
Results (errors): Errors occur in 15–20% of drug administrations when ward stock systems are used and 5–8% when individual patient systems are used. Previous allergic reactions to drugs may not be recorded more than 75% of the time.
Conclusion. ADEs are common in the Australian health system. Anticoagulant, anti-inflammatory, and cardiovascular drugs feature prominently as preventable, high impact problems, and collectively make up over one-half of all ADEs. Methods for monitoring and preventing ADEs should be progressively improved.
Interestingly, most attention to this issue has come from health economists. A report from Jeff Richardson and John McKie (Health economists at Monash) looks at the issue of better monitoring and clearer policy around patient safety in hospitals: "Reducing the Incidence of Adverse Events in Australian Hospitals: An Expert Panel Evaluation of Some Proposals" (2007). The report can be accessed at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.118.8504&rep=rep1&type=pdf
These researchers have attempted to provide a method for identifying policy options for reducing adverse events in Australia’s hospitals, in the wake of the landmark ‘Quality in Australian Health Care’ study 16 years ago in The Medical Journal of Australia Vol.163, 6 November 1995.pp.458 - 471.Many of the recommendations of that 1995 work were ignored and in this 2007 report, that lapse is examined.They believe that the magnitude of the problem of adverse events identified in the ‘Quality in Australian Health Care’ study warranted a more thorough and rapid response than has occurred.Still, they believe that viable options for reducing adverse events remain...it is not too late to do something about it.
My hope is that debate will be triggered on these issues; and that these resources might be useful to you and your students.