Professor Tracey McDonald AM PhD FACN, National Lead Clinician: Ageing, 2013
Many of us are concerned about issues of patient safety. As Professor of Ageing, I have a particular interest in the safety of older people who need to access effective health care services across the full range of care contexts. The tragic dilemma for some older people is whether it is safer to stay out of hospitals and try to manage their illness or injury conservatively, or to seek treatment in an environment that is laden with very real risks to their health.
How great is the risk to older patients?
In a review of Australian studies on medication safety ( https://www.safetyandquality.gov.au/publications-and-resources/resource-library/literature-review-medication-safety-australia) from the Australian Commission on Safety and Quality in Health Care it was found that 2–3% of all hospital admissions in Australia are medication related. But in people aged 65 years or over, this increases substantially to 20–30% of admissions.
There are also problems with transitions from hospital or the community into aged care. About 20% of patients miss their first dose of medication after arriving at an aged care facility. A large study suggests that people with missed doses are also more likely to present to hospital again within 7 days.
Even within residential aged care facilities, 40–50% of residents are prescribed potentially inappropriate medication. More than 90% of residents have at least one medication-related problem, and most have three or four. Older patients may be on multiple medications, increasing the risk of adverse events.
The Australian Commission on Safety and Quality in Health Care has a range of initiatives to improve safety and quality in medication safety: ( https://www.safetyandquality.gov.au/our-work/medication-safety)
Prescribing and monitoring errors are common problems, and patient safety can be improved by involving pharmacists at different stages of care. Studies show that safety improves when pharmacists: ( https://www.safetyandquality.gov.au/publications-and-resources/resource-library/literature-review-medication-safety-australia)
I believe that nurses can also be a big part of the solution:
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 interest. 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
While somewhat dated, information on the Australian situation was well described in 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 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. Their recommendations still resonate in today’s patient safety environment.
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 adverse drug events as medical record reviews. Of coded adverse events that contributed to death, 27% involved an adverse drug event, 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 adverse drug events. Methods for monitoring and preventing adverse drug events 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: https://www.researchgate.net/publication/5173751_Reducing_the_Incidence_of_Adverse_Events_in_Australian_Hospitals_An_Expert_Panel_Evaluation_of_Some_Proposals
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.Many of the recommendations of that 1995 work were ignored and, in this 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 ensue on these issues; and that these resources might be useful to you, your colleagues and your students.
SOURCE:
The ‘Quality in Australian Health Care’ study was published in The Medical Journal Of Australia Vol.163, 6 November 1995.pp.458 - 471
It can be accessed at: https://onlinelibrary.wiley.com/doi/abs/10.5694/j.1326-5377.1995.tb124691.x