Organisational sources of safety and danger: sociological contributions to the study of adverse events.
(17/1033)
Organisational sociology has long accepted that mistakes of all kinds are a common, even normal, part of work. Medical work may be particularly prone to error because of its complexity and technological sophistication. The results can be tragic for individuals and families. This paper describes four intrinsic characteristics of organisations that are relevant to the level of risk and danger in healthcare settings--namely, the division of labour and "structural secrecy" in complex organisations; the homophile principle and social structural barriers to communication; diffusion of responsibility and the "problem of many hands"; and environmental or other pressures leading to goal displacement when organisations take their "eyes off the ball". The paper argues that each of these four intrinsic characteristics invokes specific mechanisms that increase danger in healthcare organisations but also offer the possibility of devising strategies and behaviours to increase patient safety. Stated as hypotheses, these ideas could be tested empirically, thus adding to the evidence on which the avoidance of adverse events in healthcare settings is based and contributing to the development of theory in this important area. (+info)
A comparison of iatrogenic injury studies in Australia and the USA. I: Context, methods, casemix, population, patient and hospital characteristics.
(18/1033)
OBJECTIVE: To better understand the differences between two iatrogenic injury studies of hospitalized patients in 1992 which used ostensibly similar methods and similar sample sizes, but had quite different findings. The Quality in Australian Health Care Study (QAHCS) reported that 16.6% of admissions were associated with adverse events (AE), whereas the Utah, Colorado Study (UTCOS) reported a rate of 2.9%. SETTING: Hospitalized patients in Australia and the USA. DESIGN: Investigators from both studies compared methods and characteristics and identified differences. QAHCS data were then analysed using UTCOS methods. MAIN OUTCOME MEASURES: Differences between the studies and the comparative AE rates when these had been accounted for. RESULTS: Both studies used a two-stage chart review process (screening nurse review followed by confirmatory physician review) to detect AEs; five important methodological differences were found: (i) QAHCS nurse reviewers referred records that documented any link to a previous admission, whereas UTCOS imposed age-related time constraints; (ii) QAHCS used a lower confidence threshold for defining medical causation; (iii) QAHCS used two physician reviewers, whereas UTCOS used one; (iv) QAHCS counted all AEs associated with an index admission whereas UTCOS counted only those determining the annual incidence; and (v) QAHCS included some types of events not included in UTCOS. When the QAHCS data were analysed using UTCOS methods, the comparative rates became 10.6% and 3.2%, respectively. CONCLUSIONS: Five methodological differences accounted for some of the discrepancy between the two studies. Two explanations for the remaining three-fold disparity are that quality of care was worse in Australia and that medical record content and/or reviewer behaviour was different. (+info)
A comparison of iatrogenic injury studies in Australia and the USA. II: Reviewer behaviour and quality of care.
(19/1033)
OBJECTIVE: To better understand the remaining three-fold disparity between adverse event (AE) rates in the Quality in Australia Health Care Study (QAHCS) and the Utah-Colorado Study (UTCOS) after methodological differences had been accounted for. SETTING: Iatrogenic injury in hospitalized patients in Australia and America. DESIGN: Using a previously developed classification, all AEs were assigned to 98 exclusive descriptive categories and the relative rates compared between studies; they were also compared with respect to severity and death. MAIN OUTCOME MEASURES: The distribution of AEs amongst the descriptive and outcome categories. RESULTS: For 38 categories, representing 67% of UTCOS and 28% of QAHCS AEs, there were no statistically significant differences. For 33, representing 31% and 69% respectively, there was seven times more AEs in QAHCS than in UTCOS. Rates for major disability and death were very similar (1.7% and 0.3% of admissions for both studies) but the minor disability rate was six times greater in QAHCS (8.4% versus 1.3%). CONCLUSIONS: A similar 2% core of serious AEs was found in both studies, but for the remaining categories six to seven times more AEs were reported in QAHCS than in UTCOS. We hypothesize that this disparity is due to different thresholds for admission and discharge and to a greater degree of under-reporting of certain types of problems as AEs by UTCOS than QAHCS reviewers. The biases identified were consistent with, and appropriate for, the quite different aims of each study. No definitive difference in quality of care was identified by these analyses or a literature review. (+info)
Voluntary reporting system in anaesthesia: is there a link between undesirable and critical events?
(20/1033)
BACKGROUND: Reporting systems in anaesthesia have generally focused on critical events (including death) to trigger investigations of latent and active errors. The decrease in the rate of these critical events calls for a broader definition of significant anaesthetic events, such as hypotension and bradycardia, to monitor anaesthetic care. The association between merely undesirable events and critical events has not been established and needs to be investigated by voluntary reporting systems. OBJECTIVES: To establish whether undesirable anaesthetic events are correlated with critical events in anaesthetic voluntary reporting systems. METHODS: As part of a quality improvement project, a systematic reporting system was implemented for monitoring 32 events during elective surgery in our hospital in 1996. The events were classified according to severity (critical/undesirable) and nature (process/outcome) and control charts and logistic regression were used to analyse the data. RESULTS: During a period of 30 months 22% of the 6439 procedures were associated with anaesthetic events, 15% of which were critical and 31% process related. A strong association was found between critical outcome events and critical process events (OR 11.5 (95% confidence interval (CI) 4.4 to 27.8)), undesirable outcome events (OR 4.8 (95% CI 2.0 to 11.8)), and undesirable process events (OR 4.8 (95% CI 1.3 to 13.4)). For other classes of events, risk factors were related to the course of anaesthesia (duration, occurrence of other events) and included factors determined during the pre-anaesthetic visit (risk of haemorrhage, difficult intubation or allergic reaction). CONCLUSION: Undesirable events are associated with more severe events and with pre-anaesthetic risk factors. The way in which information on significant events can be used is discussed, including better use of preoperative information, reduction in the collection of redundant information, and more structured reporting. (+info)
Errors in health care management: what do they cost?
(21/1033)
BACKGROUND: Iatrogenic injuries are relatively common and a potentially avoidable source of morbidity. The economic evaluation of this area has been limited by the lack of good quality national data to provide an estimate of incidence, associated disability, and preventability of iatrogenic injuries. Two recent surveys, the Quality in Australian Health Care Study (QAHCS) and the Utah Colorado Study (UTCOS), have now made this feasible. AIMS: To determine the direct costs associated with iatrogenic injuries occurring in a hospital setting. METHODS: The QAHCS was used as a representative national source of information on the incidence, disability, and preventability of iatrogenic injuries. Costs were calculated using information from Australian disease related groups (AN-DRGs) relative to the injury categories. RESULTS: The cost of just 12 preventable iatrogenic injuries is significant (0.25 million US dollars) and accounts for 2-3% of the annual budget of a typical Australian community based hospital of 120 beds. Costing data provide additional useful information for policy and decision makers. CONCLUSION: Costing iatrogenic injuries is an important component of the impact of these events. An ongoing national database of iatrogenic injuries is necessary to assist in identifying the incidence of these injuries, monitoring trends, and providing data for cost estimates and economic evaluations. (+info)
What is an error?
(22/1033)
CONTEXT: Launched by the Institute of Medicine's report, "To Err is Human," the reduction of medical errors has become a top agenda item for virtually every part of the U.S. health care system. OBJECTIVE: To identify existing definitions of error, to determine the major issues in measuring errors, and to present recommendations for how best to proceed. DATA SOURCE: Medical literature on errors as well as the sociology and industrial psychology literature cited therein. RESULTS: We have four principal observations. First, errors have been defined in terms of failed processes without any link to subsequent harm. Second, only a few studies have actually measured errors, and these have not described the reliability of the measurement. Third, no studies directly examine the relationship between errors and adverse events. Fourth, the value of pursuing latent system errors (a concept pertaining to small, often trivial structure and process problems that interact in complex ways to produce catastrophe) using case studies or root cause analysis has not been demonstrated in either the medical or nonmedical literature. CONCLUSION: Medical error should be defined in terms of failed processes that are clearly linked to adverse outcomes. Efforts to reduce errors should be proportional to their impact on outcomes (preventable morbidity, mortality, and patient satisfaction) and the cost of preventing them. The error and the quality movements are analogous and require the same rigorous epidemiologic approach to establish which relationships are causal. (+info)
Developing a culture of safety in the Veterans Health Administration.
(23/1033)
CONTEXT: Weaving patient safety into the fabric of clinical activities is an increasingly important aspect of medical care. OBJECTIVE: To detail the steps taken by the Veterans Health Administration (VHA) to integrate patient safety into its organizational structure. DESIGN: Descriptive study. SETTING: VHA. DATA SOURCES: VHA documents, congressional testimony, the medical literature, the general press, and personal communications. RESULTS: The VHA leadership has taken steps to promote a culture of safety by making public commitments to improving patient safety, allocating resources toward establishment of special centers, enhancing employee education on patient safety, and providing incentives to promote safety. The VHA is also establishing one mandatory and one voluntary adverse event reporting system; in the latter case, the reporter remains anonymous. Examples of nationally mandated initiatives are bar coding of all medications and use of computerized medical record that includes order entry, laboratory and imaging results, and all encounter notes. CONCLUSIONS: The VHA's initial efforts may serve as a template for other health care organizations that wish to engineer a culture of safety. Although progress has been made, patient safety efforts require constant attention to guard against becoming a new bureaucracy or simply window dressing. (+info)
How many deaths are due to medical error? Getting the number right.
(24/1033)
CONTEXT: The Institute of Medicine (IOM) report on medical errors created an intense public response by stating that between 44,000 and 98,000 hospitalized Americans die each year as a result of preventable medical errors. OBJECTIVE: To determine how well the IOM committee documented its estimates and how valid they were. METHODS: We reviewed the studies cited in the IOM committee's report and related published articles. RESULTS: The two studies cited by the IOM committee substantiate its statement that adverse events occur in 2.9% to 3.7% of hospital admissions. Supporting data for the assertion that about half of these adverse events are preventable are less clear. In fact, the original studies cited did not define preventable adverse events, and the reliability of subjective judgments about preventability was not formally assessed. The committee's estimate of the number of preventable deaths due to medical errors is least substantiated. The methods used to estimate the upper bound of the estimate (98,000 preventable deaths) were highly subjective, and their reliability and reproducibility are unknown, as are the methods used to estimate the lower bound (44,000 deaths). CONCLUSION: Using the published literature, we could not confirm the Institute of Medicine's reported number of deaths due to medical errors. Due to the potential impact of this number on policy, it is unfortunate that the IOM's estimate is not well substantiated. (+info)