Adverse event in healthcare (Australia) - Essay Example

Adverse Event in Healthcare (Australia) Introduction Patient safety is very important in the medical field. Adverse events can result in harmful effect on a patient. This is an area of concern in Australia that improving safety and quality in health care has become a priority in many hospitals. In the medicine field, when surgery or chemotherapy is done it can always result in adverse event on the patient. No one desires to cause it. It is usually quite harmful. An adverse event can be caused incorrect dosage of drugs. There are also times when the dosage is unsuitable. All these can be termed as a medical error. Sometimes it can be termed as a side effect. This is especially when the effect is judged as a therapeutic or secondary. When it results from treatment, it can be termed as iatrogenic. They may occur when treatment is discontinued. Sometimes it occurs when the treatment is increasing or when it is starting. Adverse event's risk can be increased by using drugs that are contradicting. Sometimes doctors can have a negative prognosis of a disease because the patient has complications resulting from adverse event. This means that the patient will not react positively to the drugs given. A patient that is affected by adverse event has symptoms like weight gain or loss. One of the harmful effects is whereby the mortality of the patient is affected. There can be fluctuations in the patient's enzymes. When the physiological, macroscopic and microscopic levels of pathogens are checked in a patient with adverse effect it will always show drastic changes. Some patients become totally functionless. 1 All these changes may be irreversible or reversible. Such a patient's susceptibility to foods, chemicals or procedures may be decreased or increased. It is usually not the initial patient's condition but it is something that results from medical intervention. Adverse events on a patient are usually unintentional. When it results from healthcare management it is referred to as an injury that is iatrogenic. It is good to note that these adverse effects are preventable especially if they result from management error. This issue has raised a concern on the patient's safety in Australia. (Zelevinsky, 2001) Identification of adverse event It is good to note that adverse events are common and they do occur. One event that happens in Australia involves patients going through caesarean in hospitals. These events are common to women who are delivering. They occur while the patients are in the theatre. 2 Causal factors There are various causes to adverse event occurring in theatres during operation. It has been noted that the doctors dealing with this section are usually tired because of increase in the number of complications during delivery. Some of them just work 24 hours increasing adverse event occurrence. Some of the surgeons are quite inexperienced in the work which influences too. The doctors can have work and also family related stress which affects their performance. There is so much technological advancement and at times they simply don't have knowledge in the equipment being used. (Bates, 2001) How often it occurs Research shows that these adverse effects are occurring on a daily basis in hospitals in Australia. In fact four percent of the women who go through caesarean section of delivery show report of adverse event occurring. (Aiken and Silber, 2003) Reporting It is always good to report the occurrence of an adverse event when it occurs. However one should know that not all adverse events should be reported. When a reportable one occurs, the relevant people should be informed. So why should they be reported any way It is good because it can help in predicting the occurrences. Using this information the institution can put in place the necessary prevention measures. The recipient of the reports can find out how the adverse event originated. In this twenty first century, reporting systems need to be put in place to help in this process. These information systems help in data collection in relation to adverse events. (Makeham and Kidd 2002) There is usually a variation in the complexity of the reporting forms. They can be simple or complex. Hospitals should try and have reporting systems that are unified put in place. In the report of the adverse event it has to be adequately described. It should have a report header. There is usually a report requester. In this, a manager can access it by authentication. Reports can be generated by a report generator. The information in the request is recorded by the Repository. It is also responsible for information consolidation. This information has to be given to the concerned people. They can then put in place strategies that can be used to prevent these events. The main reason for reporting is to help in improving safety in the health care sector. 3 Investigation Research has been done in the health sector to find out the causes of adverse event in Australia. These investigations based less on individual stake holders involved. Such adverse events may be caused by an action done to a patient by a doctor or physician. Sometimes it involves the omission of an action or something leading to an adverse event occurring. When these adverse events are investigated and analyzed there are usually some shocking revelations. It is revealed that the working environment influences a lot in the occurrence of an adverse event. The investigations show that some medical practitioners simply do not follow safe practices in their medical field. An organizational context may affect the doctors and physicians or the wider stake holders in departing from the safe practice. 4 In Australia, there are investigators that deal specifically with these events. There are different ways in which they use to investigate. For instance, the staff in the hospital can be interviewed concerning the occurrence of the adverse event. This is especially done on the staffs that were on duty when the event occurred. This is because they are better placed with first hand information. Face to face interviews are good because some factors can be observed easily by the investigator. Some of these factors include whether the doctor or the person involved was simply tired. It can just be seen by the investigator very easily. Important information can also be accessed by the investigators from the records that are kept in the hospital. While records in the medical institution can be reviewed in the investigations, they are very limited in nature. This is because very minimal factors can be investigated using the records. When the investigations are carried out it is good not to individualise the errors that are made. Rather it should be dealt with in a wider scope of view. In this the investigator can ascertain the sub-optimization of care in the hospital. In conjunction he or she can find out where specifically in the hospital process it occurred. The investigator in this case can also find out in which way the clinical practices lead to the occurrence of the adverse event. It is not just about the identification of the human errors in the medical field. Rather it is about knowing in which way there is failing of complex systems in these institutions. In the process of caring for the patients medical professionals may have weaknesses leading to adverse events. Such weaknesses need to be investigated. Case record narratives are the best to be used to find out these weaknesses. 5 Analysis When an adverse event occurs the record reviews give investigator important information. These records need to be analysed. There should be a lead clinician who needs to reanalyse the review questionnaires. This analysis reveals the nature of the event. Matters concerning how it happened can be ascertained. The extent of the adverse event can also be known in the analysis. It shows the exact point in the medical process that the adverse event occurred. More information can be revealed when an analysis of the adverse event is carried out. For instance the level of education of the doctor can be known and whether it may have contributed to the occurrence. This information is then used to make the necessary conclusions in the occurrence of the adverse event. Investigators and the lead clinician that is dealing with these matters need to be open-minded and unbiased for the investigations and the analysis to be successful. The lead clinician has to find out whether there was immediate and adequate assessment of the patient before he or she was released from hospital. He or she has to find out whether there was any discontinuation in care that is given to the patient. He has to find out whether other people like dieticians and physiotherapists were adequately involved. The other thing is to know whether the observations made by the nurses on the patient were recorded and if the clinical recordings included these observations. The lead clinician has to find out whether the medical practitioner was qualified to do the job or not. If this is adequately done it can help in improving safety and quality in health care sector. 6 Technology Technological advancement in the health care industry is very important. In this twenty first century there are very many inventions each day. Health professionals sometimes don't know how to operate this knew machines there fore leading to adverse events occurring. The doctors need to be taught how to operate these new inventions. To help improve safety in the healthcare sector in Australia, technological advancement has to be integrated in the hospitals. There is need to put information systems that are cross hospital in nature. An example is the integration of web services in hospitals in Australia. All the health care processes in hospitals can have patterns of design integrated. The clinical repositories of patients can be done in a multiple way using Service Oriented Architectures (SOA). There can be improvements in the processes of testing by using technology. Research shows that most hospitals just do their scans in digitized form. The scanners in hospitals are not networked. When information is needed in another part of the hospitals it has to be carried manually. In most cases they are in hard copy form. Sometimes people using them don't return to central file. This leads to patients being kept on hold just because their information needed by doctors cannot be accessed. Patient care delivery Adverse events in the health care sector may occur in the patient care process. This can occur by a nurse administering an under dose or an over dose of drugs on the patient. Research shows that some health professional may have so many patients to deal with till they affect his or her efficiency. There needs to be improvement in the patient care delivery. Patients always need attention in hospital to ensure there well being. Routine checks on the patients have to be done in good time. The people carrying out the patient care need to record how the patient is faring on. 7 Organizational structures This involves the management of hospitals in Australia. There are incidences when the medial practitioner or professional is employed not on merit but due to other factors. This will always lead to an increase in the occurrence of adverse events in hospitals. There are simple things in hospitals like the filling system that can affect occurrence of adverse events. In hospitals sometimes the management fails to make important decisions very fast. Such delays affect the degree of adverse events occurring in hospitals. The management in hospitals need to be organized and do first things first. This will hep in improving the quality and safety in the health care sector in Australia. MINIMISING THE ADVERSE EVENTS Management development in workforce Adverse events in the health care sector may not be eliminated but they can be minimised. One of the ways is to carry out management development. This is where the doctors learn as they continue with their duties. It can be done formally and informally. Both ways are important and can lead to minimising adverse events. There should be seminars and workshops where the health professionals are taught. This helps the professionals to acquire and up date their skills in relation to technological advancement. Surveillance in the organisations This can help to minimise adverse events occurring. The managers in hospitals that are simply lax in doing their work have to be done away with. The health professionals have to be assessed frequently. Those that are underperforming should be spotted and the necessary measures taken. This can help to prevent further harm on the patients by these professionals. 8 Service planning Managers in hospitals should ensure that the professional are enough considering the number of patients they speculate to have. They then have to carry out planning on who has to be on duty at what time. There has to be a time when the professional have offs and leave from work. This will help to eliminate the issue of tired doctors at work. They should be given enough time to rest. This has to involve good planning such that the ones on duty are not overworked. The giving of off-duty to staff should be balanced. There are incidences when most of the doctors are on off duty and the few that are present are overworked. Improve systems The systems in hospitals should be improved. Especially the reporting systems in hospitals are very important. Sometimes there are very complex systems in hospitals that the professional cant adequately used. I propose that these systems should be simplified. The ones that are malfunctioning should be done away with. This will help to minimise the occurrence of adverse events in health care sector. 9 Conclusion Adverse events have not started happening recently in Australia. It is something that has been occurring before. Research shows that in 1950s and 1960s there were there but nobody bothered about them. Of late there has been a concern in the occurrences of adverse events in health care sector. While some people argue that it is human to err, it is good to put in measures that will minimise these occurrences. When management development is well carried out it will help in minimising the adverse events in Australia. There should be service planning that will help in minimising tired professionals at work. Surveillance of the health professionals should be done and poor performers should be done away with. The truth of the matter is that human life is so precious so let us hold hands and minimise these occurrences. References Aiken, L. and Silber, J. (2003): Educational levels of hospital nurses and surgical patient mortality; Jama; 290; 1617-1623 Bates, D. (2001): Reducing the frequency of Errors in Medicine Using Information Technology; Jamia; 8; 299-308 Brennan, T. and Laird (N. 1991): Incidence of adverse events and negligence in hospitalised patients; North England Journal of Medicine; 324: 370-6 Classen, D. and Pestotnik, S. (1991): Computerised surveillance of adverse drug events in hospital patients; JAMA; 266, 2847-51 Gawande, A. and Thomas J. (1999): The incidence and nature of surgical adverse events in Colorado and Utah in 1992; Surgery; 126; 66-75 Kohn, L. and Donaldson, M. (1999): To Err is Human; building a safer health system, Washington, D.C; National Academy Press Lederman, R and Parkes, C. (2002): Removing the Barriers to Improved Prescribing Decisions; Using Information Systems to Improve Health Care; Proceedings of the Tenth National Health informatics Conference; Melbourne; Vic Makeham, M. and Kidd, M (2002): 'An international taxonomy for errors in general practice; a pilot study' Medical Journal of Australia (177:2); pp 68-7 Wilson, R. and Hamilton J. (1995): The Quality in Australian Health Care Study; Med Journal of Australia; 163(9); 458-71 Zelevinsky, K. (2001): Nurse staffing and patient outcomes in hospitals; New England Journal of Medicine; 346(22); 1715-17 Read More