Adverse Events
Adverse events are unexpected negative outcomes caused by the care itself rather than the underlying condition of the patient.
Are adverse events preventable?
Some adverse events are preventable; others are not.
Hazards, equipment breakdowns, and procedural errors are a risk in any complex work environment. Safely prescribing and administering medicines, and performing surgical procedures, laboratory tests, or radiological investigations often require complex interactions of people and technology. Each of these instances brings with it an element of risk.
It is the role of quality management to reduce risks.
Unfortunately, some things just can not be prevented, but we are actively seeking solutions to those that can.
- Error cannot be eliminated, but we can design systems to reduce the possibility of errors so that
- they can be more easily recognized and stopped
- the adverse effects of error that are not detected or blocked can be reduced
How can you reduce the chance of error?
- Reducing error requires us to look at system solutions ... ones that do not seek to blame an individual; rather, get to the underlying problem in the system to reduce the possibility of the same thing happening again.
- Reducing errors also requires
- increasing the use of automatic prompts and checklists instead of relying on memory only
- clear communication among those providing care when it is being handed off from one care provider to another
- supporting patients/residents' involvement in their own care
Where do adverse events occur?
- Adverse events can occur anywhere in the health system– hospitals, clinics, outpatient centres, doctor's offices, nursing homes, pharmacies, patients' homes. They can involve, among other things, medicines, surgery, diagnosis, equipment, and tests.
What is the most frequently reported adverse event?
- Among the most visible and highest reported adverse events are those related to medicines. This would include things such as allergic reactions or dangerous drug interactions. It is important to let those providing your care know every medicine you are taking, including over-the-counter drugs and information on known drug allergies. It could save your life.
Examples of adverse events
Preventable
- Mrs. Walters is 86 years old and has been hospitalized for pneumonia. She has told the doctor the names of the prescription medicines she is taking because of other medical conditions. However, she forgot to mention that she is taking over-the-counter medicine. The medicine the doctor prescribes has dangerously interacted with the over-the-counter medication and has made Mrs. Walters very ill.
- While in hospital, Ms. Jones has slipped and fallen on her way to the washroom.
Unpreventable
- John Jacobs is 18 years old and has had surgery for appendicitis. When given pain medicine, he has an allergic reaction. No one knew that he was allergic to the medicine.
- Despite being an excellent candidate for transplantation, Mrs. Jones' body rejects her donor kidney.