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Reducing the Incidence of Adverse Events in Australian Hospitals: An Expert Panel Evaluation of Some Proposals

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Abstract

The aim of this paper is to demonstrate a method for identifying policy options for reducing adverse events in Australia’s hospitals, which could have been adopted, but was not adopted, in the wake of the landmark 1995 ‘Quality in Australian Health Care’ study, and to indicate the lapse time before these measures could be expected to have a major effect. The study used a quasi Delphi technique that first elicited options for reducing adverse events from an expert panel and then collated and returned them for re-consideration and comment. Completed responses from both stages were obtained from 20 experts selected on the basis of their expertise, position and publications in the area of adverse events and quality assurance. Forty-one options were identified with an average lapse time of 3.5 years. Hospital regulation had the least delay (2.4) years, and out of hospital information the greatest (6.4 years). Following identification of the magnitude of the problem of adverse events in the ‘Quality in Australian Health Care’ study a more rapid response was possible than occurred. Viable options for reducing adverse events remain.

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... Australian studies have estimated that direct hospital costs of adverse events in Australia range between $483 million and $900 million per annum. 4,5 It is estimated that money spent on medication will have to be supplemented with other money spent to treat the new health problems caused by medication. Moreover, Edmonds (2006) asserted the importance of indirect costs, often not calculated, including increased insurance premiums, lost opportunity costs, and human costs to both patients (e.g. ...
... These serious problems arising from adverse events in hospitals have made patient safety a priority in the health policy agenda. 1 Unfortunately, many adverse events happening in hospitals were avoidablein fact, half the adverse events are preventable. 6 Correlating with this, Webb et al. (cited in Richardson & McKie, 2007) 5 found that half the adverse events in the quality of health care study had a high preventability score, and that 60% of the resulting deaths should be avoidable. In addition, detecting adverse events will let hospitals to learn from the mistakes. ...
... These serious problems arising from adverse events in hospitals have made patient safety a priority in the health policy agenda. 1 Unfortunately, many adverse events happening in hospitals were avoidablein fact, half the adverse events are preventable. 6 Correlating with this, Webb et al. (cited in Richardson & McKie, 2007) 5 found that half the adverse events in the quality of health care study had a high preventability score, and that 60% of the resulting deaths should be avoidable. In addition, detecting adverse events will let hospitals to learn from the mistakes. ...
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AbstrakDeteksi terjadinya kejadian yang tidak diharapkan (KTD) telah menjadi salah satu tantangan dalam keselamatan pasien oleh karena itu metode untuk mendeteksi terjadinya KTD sangatlah penting untuk meningkatkan keselamatan pasien. Tujuan dari artikel ini adalah untuk membandingkan kelebihan dan kekurangan dari beberapa metode untuk mendeteksi terjadinya KTD di rumah sakit, meliputi review rekam medis, pelaporan insiden secara mandiri, teknologi informasi, dan pelaporan oleh pasien. Studi ini merupakan kajian literatur untuk membandingkan dan menganalisa metode terbaik untuk mendeteksi KTD yang dapat diimplementasikan oleh rumah sakit. Semua dari empat metode telah terbukti mampu untuk mendeteksi terjadinya KTD di rumah sakit, tetapi masing-masing metode mempunyai kelebihan dan kekurangan yang perlu diatasi. Tidak ada satu metode terbaik yang akan memberikan hasil terbaik untuk mendeteksi KTD di rumah sakit. Sehingga untuk mendeteksi lebih banyak KTD yang seharusnya dapat dicegah, atau KTD yang telah terjadi, rumah sakit seharusnya mengkombinasikan lebih dari satu metode untuk mendeteksi, karena masing-masing metode mempunyai sensitivitas berbeda-beda.AbstractDetecting adverse events has become one of the challenges in patient safety thus methods to detect adverse events become critical for improving patient safety. The purpose of this paper is to compare the strengths and weaknesses of several methods of identifying adverse events in hospital, including medical records reviews, self-reported incidents, information technology, and patient self-reports. This study is a literature review to compared and analyzed to determine the best method implemented by the hospital. All of four methods have been proved in their ability in detecting adverse events in hospitals, but each method had strengths and limitations to be overcome. There is no ‘best’ single method that will give the best results for adverse events detection in hospital. Thus to detect more preventable adverse events, or adverse events that have already occurred, hospitals should combine more than one method of detection, since each method has a different sensitivity.
... [Hollingsworth, 1998, Richardson, 2007, Hendrich, 2008, Stanton, 2004, Lyons, 2008. Dabei wurde herausgefunden, dass Krankenschwestern zwischen 6 und 8 km während einer 10 Stundenschicht laufen. ...
... Eine Delphi-Studie der Monash Universität [Richardson, 2007] In ähnlichen Studien [Hollingsworth, 1998, Hendrich, 2008, Burke, 2000 Storfjell [Storfjell, 2008] Eine weitere Studie von Fernandez [Fernandez, 2007] beschäftigt sich mit der Implementierung einer Plattform zum Austausch von Patientendaten. Diese Studie untersucht die Vorteile und Risiken bei der Implementierung eines Patientenakten-Austauschsystems. ...
... The impact of medical errors in Australia is also a concern. In one study examining the impact of medical errors in Victoria, it was found that 7% of routine admissions were associated with an AE (Richardson & McKie, 2007). The Quality in Australian Health Care Study in 2005 (QAHCS; Wilson et al., 1995) examined medical records for 14,000 admissions to 28 hospitals in NSW and SA and found that there were 470,000 admissions/year (10-15% of hospital admissions) associated with an AE leading to approximately 18,000 deaths and 50,000 cases of permanent disability. ...
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Background Health professionals avoiding difficult conversations with each other can lead to serious negative consequences for patients. Clinical supervisors are in the unique position of interacting both with students as well as colleagues and peers. This study explores the avoidance of difficult conversations from the perspective of clinical supervisors in order to better understand why health professionals avoid difficult conversations. Objective This study aimed to identify the reasons why difficult conversations are avoided between health-care professionals and to gain deeper insight into the phenomenon of avoiding difficult conversations in general. Methods Convergent interviewing was used with 20 clinical supervisors to explore the following question: Why do you think that people in your workplace avoid difficult conversations? Results Major reasons for avoiding difficult conversations included the fear of negative consequences, a general distaste for confrontation, and a lack of confidence in their skills to have such conversations. Additional factors included individual qualities such as personality type and communication style, available time, size of the workplace, and a range of perceived cultural barriers standing in the way of having difficult conversations. Conclusion There is a need to encourage clinical supervisors and other health professionals to embrace difficult conversations to reduce adverse events and enhance patient outcomes. This requires additional training and educational opportunities to enhance knowledge, skills, and confidence to plan and engage in difficult conversations. Some types of difficult conversations require more skills than others.
... Given the alarming frequency and seriousness of medication errors, it is in these extremely busy environments where the closest supervision is required, but time pressures detract from quality supervision. 32,44 Clinical supervisors need to provide essential knowledge, skills, support and encouragement to students and the placement organisation has to navigate and coordinate student semester breaks and the overall schedule of the preceptors. 9,11 Failure to deal with these challenges has eroded the quality of the experience into a "tick-the-box" paperwork exercise that leaves all parties feeling fatigued and unfulfilled. ...
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Background: The importance of effective clinical supervision for emerging clinicians is well recognised, not only for practice preparation, but also for reducing future attrition rates. Also recognised are the challenges faced by both students and supervisors during the supervision experience. This study aimed to identify the qualities of the "ideal" clinical supervision environment from the perspective of clinical supervisors from both nursing and allied health. Design: A qualitative study using an interview method based on action research. Methods: The convergent interview method was used with 20 clinical supervisors and educators from nursing and allied health across Victoria. Interviews were recorded and data analysis occurred at the end of each pair of interviews to develop deeper questions in line with the method. Results: 12 major themes emerged as "ideal" qualities with a range of suggestions on how these can be achieved. Conclusion: The "ideal" qualities can be used in assessing and improving current contexts, as well as designing new clinical supervision processes, models, programs and guidelines or policies. The convergent interview method allowed for deeper level analysis than previous research.
... Additional costs due to poor clinical handover have not been examined, but [12] reports that 18% of patients felt that time was wasted because their care was poorly organised after discharge. Direct hospital costs of adverse events are estimated as AUD $900 million per year [13]. ...
... The human and financial cost of medical errors has been well documented. [4][5][6][7] Much of the research exploring ways to overcome difficult conversations, however, relates to those conversations between a clinician and a patient or patient's family. Given the importance of enabling difficult conversations in the clinical environment in general, there is a need to develop strategies, processes, and tools that can be used by clinicians to have difficult conversations, such as those about mistakes and disrespectful behavior, not only with their students but also with their seniors, peers, and other colleagues. ...
Article
Background: Clinical supervisors are responsible for managing many facets of clinical learning and face a range of challenges when the need for "difficult" conversations arises, including the need to manage conflict and relationships. Methods: Spotlight on Conversations Workshop was developed to improve the capacity of clinical supervisors to engage in difficult conversations. They were designed to challenge the mindset of clinical supervisors about difficult conversations with students, the consequences of avoiding difficult conversations, and to offer activities for practicing difficult conversations. Preworkshop, postworkshop, and 4-month follow-up evaluations assessed improvements in knowledge, intent to improve, and confidence along with workshop satisfaction. Results: Nine workshops were delivered in a range of locations across Victoria, Australia, involving a total of 117 clinical supervisors. Preworkshop evaluations illustrated that more than half of the participants had avoided up to two difficult conversations in the last month in their workplace. Postworkshop evaluation at 4 months showed very high levels of satisfaction with the workshop's relevancy, content, and training, as well as participants' intention to apply knowledge and skills. Also shown were significant changes in participants' confidence to have difficult conversations not only with students but also with other peers and colleagues. In follow-up in-depth interviews with 20 of the 117 participants, 75% said they had made definite changes in their practice because of what they learned in the workshop and another 10% said they would make changes to their practice, but had not had the opportunity yet to do so. Conclusion: We conclude that the Spotlight on Conversations Workshop can improve the clinical supervisor-student relationship as well as build general difficult conversation capacity for a range of stakeholders in clinical settings.
... Around the world, different health-professional regulation models are being investigated in response to community demands for more transparent mechanisms (Dixon, 2007;Braithwaite et al., 2005;Paterson, 2012). Medical scandals, plus uncontested evidence of substantial harm to patients resulting from healthcare, undoubtedly play a role (Davies, 2007), together with correcting preventable errors (Kohn et al., 2000;Department of Health, 2000;Richardson and McKie, 2007). ...
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Purpose: The purpose of this paper is to explore approaches to the regulation of healthcare complaints and disciplinary processes. Design/methodology/approach: A literature review was conducted across Medline, Sociological Abstracts, Web of Science, Google Scholar and the health, law and social sciences collections of Informit, using terms tapping both the complaints process and regulation generally. Findings: A total of 118 papers dealing with regulation of health complaints or disciplinary proceedings were located. The review reveals a shift away from self-regulation towards greater external oversight, including innovative regulatory approaches including "networked governance and flexible or "responsive" regulation. It reports growing interest in adoption of strategic and responsive approaches to health complaints governance, by rejecting traditional legal forms in favor of more strategic and responsive forms, taking account of the complexity of adverse health events by tailoring responses to individual circumstances of complainants and their local environments. Originality/value: The challenge of how to collect and harness complaints data to improve the quality of healthcare at a systemic level warrants further research. Scope also exists for researching health complaints commissions and other "meta-regulatory" bodies to explore how to make these processes fairer and better able to meet the complex needs of complainants, health professionals, health services and society.
... It is also true, however, that many patients have died as a consequence of conventional medical practitioners practicing negligently, or failing to refer or recognise the limitation of their own expertise, or failing to follow up with patients. Many thousands of patients die each year due to medical errors or other adverse events related to conventional medical treatments (Richardson and McKie 2007). While, in each case, these are disutilities, it does not necessarily follow that this makes either form of practice unethical, let alone disreputable or illegitimate. ...
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Recent discourses about the legitimacy of homeopathy have focused on its scientific plausibility, mechanism of action, and evidence base. These, frequently, conclude not only that homeopathy is scientifically baseless, but that it is "unethical." They have also diminished patients' perspectives, values, and preferences. We contend that these critics confuse epistemic questions with questions of ethics, misconstrue the moral status of homeopaths, and have an impoverished idea of ethics-one that fails to account either for the moral worth of care and of relationships or for the perspectives, values, and preferences of patients. Utilitarian critics, in particular, endeavour to present an objective evaluation-a type of moral calculus-quantifying the utilities and disutilities of homeopathy as a justification for the exclusion of homeopathy from research and health care. But these critiques are built upon a narrow formulation of evidence and care and a diminished episteme that excludes the values and preferences of researchers, homeopaths, and patients engaged in the practice of homeopathy. We suggest that homeopathy is ethical as it fulfils the needs and expectations of many patients; may be practiced safely and prudentially; values care and the virtues of the therapeutic relationship; and provides important benefits for patients.
... Its report was shelved after a challenge to the validity of the QAHC study. This resulted in a study by Runciman et al. [2], the creation of an expert 'group' of four and, eventually, the Australian Council for Safety and Quality in Health Care (ACSQHC) in 2000 [6]. This in turn has been replaced by the Australian Commission on Safety and Quality in Health Care. ...
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Medical News Today (2004). "Publishing Surgeons' Performance Remains Controversial." (http://www.medicalnewstoday.com/medicalnews.php?newsid=12319).
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Australian Council for Safety and Quality in Health Care (2004b). Safety Innovations in Practice (SIIP) Program Mark II, Compendium of Project Reports.
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Grabowski, D. C. and E. C. Norton (2006). Nursing Home Quality of Care. The Elgar Companion To Health Economics. A. M. Jones. Cheltenham, UK, Edward Elgar.
CEC) was launched, as part of the New South Wales Patient Safety and Clinical Quality Program. It's mission is 'to build confidence in healthcare in NSW, by making it demonstrably better and safer for patients and a more rewarding workplace
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The Scandal of 'Dr Death The Age
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Chandler, J. (2005). " The Scandal of 'Dr Death'. " The Age. May 28.
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Australian Council for Safety and Quality in Health Care (2003e). Safe Staffing: Discussion Paper.