First Do No Harm: Reducing Adverse Events in Public Hospitals
Report 10 - October 2007
Background
The vast majority of patients that enter our public hospitals every year
are treated safely and without incident. In some cases incidents occur,
some of which unintentionally harm patients. Those incidents which cause
harm are generally referred to as adverse events.
The outcome of an adverse event for a patient can vary from minor to
severe, and harm can include extended hospital stay, emotional distress,
suffering, disease, injury disability and/or death.
Findings from research in Australia and overseas indicate that around
10 per cent of patients experience an adverse event while in the hospital
system, and that around 50 per cent of adverse events may be preventable.
Research also shows that adverse events are often the result of system
problems where multiple factors contribute to an incident.
WA Health’s incident reports show that in 2006, there were 25 769
clinical incidents. Based on reports finalised by 30 June 2007, 15 614
resulted in harm to patients. Of these, 820 were rated as critical, causing
serious harm or death.
As well as causing harm to patients and distress to their families, adverse
events consume healthcare resources. WA Health estimates that adverse
events in WA may have cost up to $380 million in 2005-06. Reducing adverse
events offers the opportunity to release significant resources to treat
additional patients and invest in safety improvements.
WA Health is responding to the issue of patient safety, and hospitals
manage and investigate incidents and adverse events. The examination focused
on two key questions:
- Are there good systems in place to report and analyse adverse events
in WA public hospitals?
- Does WA Health learn from adverse events by implementing solutions
to reduce them and measure their effectiveness in doing so?
What the examination found...
- The incidence of adverse events appears to be similar to that elsewhere.
- WA Health has established state-wide incident reporting, but there
are deficiencies that limit its understanding of adverse events:
- there is under-reporting of events, we estimate that almost one-third
of adverse events were reported in 2006
- reporting is not improving overall, although some hospitals have
significantly improved their reporting
- information is not timely, more than half of unclassified cases
are more than six months old
- a coordinated approach to improving reporting is lacking.
- WA Health is not systematically using all available information sources
to build a more complete understanding of adverse events.
- WA Health has the foundations of a coordinated approach to adverse
events, but key elements needed to achieve system-wide improvements
are not yet in place:
- implementation of the clinical governance structures that support
and reinforce reductions in adverse events is patchy
- system-wide priorities based on the situation in WA have not been
developed
- while there are examples of local improvements, information is
not systematically shared between hospitals and across the system
- WA Health does not have a structured program of monitoring and
evaluation.
What the examination recommended...
WA Health should improve its understanding of adverse events by:
- increasing reporting and improving the timeliness of data
- making systematic use of all available data sources
WA Health should improve learning from adverse events by:
- setting system-wide priorities based on a better understanding of
the situation in WA
- increasing the sharing of information between hospitals and across
the system
- implementing a coordinated program of monitoring of initiatives and
evaluation of progress
Health services and hospitals should have effective structures and systems
to drive reductions in adverse events.
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