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ADVERSE EVENTS: OUR RESPONSIBILITY FOR REPORTING, REVIEWING AND RESPONDING
Author(s) -
Watters D. A.
Publication year - 2009
Publication title -
anz journal of surgery
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.426
H-Index - 70
eISSN - 1445-2197
pISSN - 1445-1433
DOI - 10.1111/j.1445-2197.2009.04928_2.x
Subject(s) - medicine , adverse effect , harm , audit , blame , root cause analysis , medical emergency , patient safety , health care , liability , intensive care medicine , psychiatry , management , forensic engineering , finance , economic growth , political science , law , economics , engineering
An adverse event is defined as unintentional harm (to a patient) arising from an episode of healthcare and not due to the disease process itself. Surgical adverse events include death, unplanned reoperation, unplanned readmission, unplanned ICU readmission, medication errors and side‐effects, falls, pressure ulcers, hospital acquired infection, and inadvertent injury during surgery. Adverse events occur in around 10% of general surgical cases. The rates also vary between specialties. Reporting: Adverse events need to be reported through both a hospital incident reporting system (eg Riskman) and through surgical audit. Each adverse event should be graded using a Severity Assessment Code (1–4) on the basis of its effect on the patient or hospital service, and the likelihood of it recurring. Some of the more severe events will trigger an entry on the risk register, making service managers responsible for action. Reviewing: The opportunity must be seized to improve system issues. An investigation (eg root cause analysis) should be conducted in an atmosphere of ‘no‐blame’ with engagement of and consultation with the major stakeholders who are responsible for delivering solutions. Training in system‐wide approaches and teamwork can be invaluable. Responding: The response needs to recognise the needs of the patient who has been harmed. There should be an honest and frank discussion with the patient and/or their family, acknowledging their suffering with empathy and an apology should be offered without necessarily admitting any liability. Open disclosure has the potential to reduce risk of litigation. Surgeons need to engage in reporting, reviewing and responding if the rate of adverse events is to be reduced.