Patient Safety

A Global Problem

Health care is a complex system that can go wrong in many different ways. At best this results in inefficiency, delay and irritation. At worst, patient safety may suffer, resulting in injury or even death to patients receiving care. Preventable harm in the health care environment - that which is caused by the processes of health care rather than an underlying disease or external accident - is known as "iatrogenic harm".

Tragically, this kind of harm to patients is all too common. The risk of iatrogenic death being associated with admission to an acute care hospital is 40 times greater than that of dying from a traffic accident and 400 times greater than the risk of death associated with working in the chemical industry4. Analysis of large studies in the US and Australia (supported by smaller studies in the UK, New Zealand and Denmark) have shown that one in ten admissions to acute care hospitals is associated with an adverse event and that one in five of these contribute substantially to death (0.3% of admissions) or major disability (1.7% of admissions) 5, 6.

The direct medical costs of iatrogenic harm are estimated to amount to 5% of the total amount spent on health care with a further 1% consumed by litigation and compensation. Unfortunately, this is only part of the cost. "Whole of life" costs for those who suffer harm, the people who care for them and those who provided the health care are estimated to be at least twice this amount and do not include the emotional costs to those involved4.


What is an Incident?

An incident is any event or circumstance that could have or did cause unintended harm, suffering, loss or damage. An incident in the health care context may or may not involve an error on the part of the health care team and may or may not be preventable. However, the majority of incidents or problems reported can be prevented by:

* altering work practices and processes
* modifying the workplace, infrastructure or equipment
* awareness and education.

What is Incident Monitoring?

In the health care context, incident monitoring involves the voluntary reporting of events which:

* could have or did harm a patient, visitor or staff member
* involve malfunction, damage or loss of equipment or property
* could lead to a complaint or litigation.


When things do go wrong it is important to find out not only What happened?, Where? and When? but also to carefully and consistently draw out the underlying causes and contributing factors-How? and Why? the incident occurred. Incident reports can be generated by the people involved in an incident (staff, patients and visitors) or by people who witnessed or suffered from the incident. First-hand information can provide valuable insight into how and why the incident occurred so strategies can be devised to prevent similar occurrences.

Incident monitoring enables organisations to identify particular areas of concern and devise interventions. Successful implementation of incident monitoring by health units has been followed by improved individual staff morale with fewer personnel feeling completely powerless to effect change.

Explicit criteria for assessing the degree of risk can be expressed as a “risk matrix” which enables the severity of the outcome old an incident to be plotted against the likelihood of the incident recurring (see diagram below). This can be used as a tool to set priorities and identify areas that require root cause analysis of further attention.

Many of the things that can go wrong in the health care environment do so very infrequently and may only be seen in an individual health unit - even a large one-once or twice a year7. An individual organisation would therefore take an unacceptably long time to build up sufficient data to characterise these problems and understand the relevant causal factors. For this reason, AIMS collects and aggregates de-identified incident data into local, state, national and international databases. Such depth and breath of coverage is vital for providing the information necessary for developing system-wide strategies to better detect, manage and prevent problems.


The New International Classification for Patient Safety (ICPS) from the World Health Organization

Modern health systems struggle to share and access health information, resulting in massive waste and frequent avoidable harm to patients. A big part of the problem is a lack of standardised terminology. The new International Classification for Patient Safety (ICPS ) from the World Health Organization (WHO) is an important step in addressing the problem. Using this common classification, healthcare providers all over the world will be able to speak the same language - enabling them to compare performance, to learn from one another and to consider rare but catastrophic accidents that can only be detected and understood in very large data collections.

For more information about this important project visit the APSF site or the ICPS page of the WHO website.

A Delphi process conducted by the World Alliance for Patient Safety to gather comments on the ICPS is now under way. This process is designed to obtain vitally important feedback on the proposed conceptual framework, concepts and terms. Practitioners and other experts interested in patient safety are invited to participate in the Delphi Survey.

As a result of the feedback received through the Delphi Survey, the ICPS will be further revised. Field testing will commence in 2007. It is envisioned that the finalised version of the ICPS will be available in 2008.

Reference
4 Runciman, WB, Moller J, Iatrogenic Injury in Australia, 2001
5 Runciman WB, Edmonds MJ, Pradhan M, Setting Priorities for Patient Safety. Qual Saf in Health Care 2002 (11; 224-229)
6 Runciman WB, Webb RK, Helps SC, Thomas EJ, Sexton EJ, Studdert DM et al, A comparison of iatrogenic injury studies in Australia and the USA II: reviewer behaviour and quality of care. Int J Qual Health Care 2000 (12(5):379-388).
7 Runciman WB, Edmonds MJ, Pradhan M, Setting Priorities for Patient Safety. Qual Saf in Health Care 2002 (11; 224-229)

Source : http://www.patientsafetyint.com