When patients are harmed in hospital, issues aren’t always fixed to avoid it happening again

Over the past two weeks, the media has reported several cases of serious “adverse events”, where babies, children and an adult experienced harm and ultimately died while receiving care in separate Australian hospitals.

When a serious adverse event occurs, hospitals investigate what happened and why, and propose recommendations to reduce the risk of similar harm occurring again.

About 1,600 patient safety investigations are undertaken each year. And the stakes are high. If not managed well, the hospital’s response can compound the psychological harm to the patient and their family. If lessons aren’t learnt, patient safety doesn’t improve.

Despite three decades of concerted effort, the rate of adverse events remains stubbornly high in Australia. One in ten people will experience harm associated with their hospital care.

What can be done to reduce this harm? There is no quick fix but our research shows improving hospital investigations can have a big impact. Here’s how this can be done.

What exactly are ‘adverse events’?

Thirty years ago, one of the first large-scale studies of the rates of harm to patients in Australian hospitals was published – the Quality in Australian Health Care Study.

Alongside subsequent studies in other countries, it found one in ten hospital admissions were associated with an “adverse event”. These included:

• incidents with medications (such as administering the wrong dose or drug)

• hospital-acquired infections (associated with surgery or intravenous lines)

• physical or mental health deterioration which is not detected and managed in a timely way.

Some adverse events can lead to patients suffering serious or permanent physical disabilities and psychological trauma.

Clinicians involved in such events can also suffer significant psychological distress and grief.

How are they investigated?

When a serious adverse event occurs, hospitals form a team to undertake a patient safety investigation. The teams harness experts from the clinical specialties involved in the adverse event (such as emergency department or surgery) and health service safety personnel.

The investigation also informs “open disclosure” – information for the patient and family about why the adverse event occurred and what changes the health service intends to make to prevent a similar adverse event from happening again.

But our research has shown most recommendations in these investigations are unlikely to reduce harm to patients.

The complexity of health care, workforce shortages and broader pressures on the health system (such as an ageing population requiring more complex care) often work against health services effectively implementing recommendations.

So what can be done?

We are undertaking research with four state and territory governments (New South Wales, Victoria, Queensland and the Australian Capital Territory) to test these strategies and inform how they can be redesigned for safer care. Here’s what we’ve found so far.

A well-recognised problem with some investigations is their lack of specialised expertise in patient safety. The field is backed by robust research, yet often the people undertaking the investigations are experts in their clinical field, or in the running of a hospital, but not in safety science.

Added to that, the sheer complexity of health care makes the task of finding the factors that contributed to the harm and developing effective recommendations even more challenging.

Consider the contrast this has with biomedical sciences, such as developing new drugs or tests. These use large, specialist, independent research institutions with highly trained scientists. Yet patient safety problems, which are arguably as complex, are expected to be solved with fewer resources, using part-time staff with variable task-specific experience and training, at a local hospital.

Complex patient safety problems require appropriate investments in expertise and independence.

Findings of investigations tend not to be shared. This means learning remains local. Repeated investigations of the same type of adverse event may be undertaken at multiple hospitals, duplicating effort.

More sharing of adverse events by hospitals and health departments would reduce this duplication and make learning more efficient. Aviation does this well. If a commercial jet experiences a problem or near miss, the issue is shared so every airline knows about it.

If we did this, we could redesign hospital systems to support safer care. This could, for example, include standardising how medication information, such as the dose, is displayed on all hospital computer systems. Doctors going from one hospital to another would be less likely to make errors in prescribing medication, which is a common patient safety risk.

Thirty years after the rates of adverse events were first reported in Australia, patients and the broader public deserve to know that investigations are being conducted effectively and that strategies are being adopted to keep every hospital visit safer.

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