Are we under reporting adverse events

When Irish figures were compared to other developed countries’ rates of adverse events it suggested under-reporting in the Irish system, Dr. Amanda Phelan HMI West Forum in Merlin Park Hospital, Galway.  Maureen Browne reports.

Maureen Browne
Maureen Browne

There were 76,842 adverse hospital events reported to the National Treasury Management Agency (NTMA) in 2012, Dr. Amanda Phelan, Associate Dean for Global Engagement in the School of Nursing, Midwifery & Health Systems and Co-Director of the National Centre for the Protection of Older People in UCD, told the HMI West Forum in Merlin Park Hospital, Galway. This represented 2.9% of the total 2.6 million hospital in patient and A & E attendances during that year.

She said an adverse event was defined by Attarian (2008:1) as an incident which ‘causes an injury to a patient as the result of a medical intervention rather than the underlying medical condition. It represents an unintentional harm to a patient arising from any aspect of healthcare management.’ However, when Irish figures were compared to other developed countries’ rates of adverse events (4-16%), it suggested under-reporting in the Irish system.

Dr. Phelan indicated that within frameworks of high standards in clinical governance and within legislation (NTMA Act 2000), State authorities were obliged to report adverse incidents promptly to the Sate Claims Agency (located within the NTMA) and State authorities were also required to develop and implement risk mitigation strategies locally.

The commonest adverse event reported to the NTMA in 2012 was slips/trips/falls.

She said the commonest adverse event reported to the NTMA in 2012 was slips/trips/falls, which accounted for 33.3 per cent of the total reports.  Violence/harassment/aggression/abuse was the second most common form of adverse event (12.9 per cent) followed by medication incidents at 7.8 per cent of the total reported incidents (NTMA 2013).

In considering the area where the adverse event occurred, the NTMA indicated that reports in 2012 identified that 25 per cent occurred within the speciality of medicine, with the disability specialty being second (16.4 per cent) and mental health areas reporting the third highest figure (12.4 per cent). In terms of who reported the adverse incident, nurses and midwifery staff (79.7 per cent) were the highest reporters, with health and social care staff reporting 8.3 per cent, allied health care professionals 6.2 per cent and medical professionals representing 3.0 per cent of reporters.

One of the prominent examples of adverse events globally was medication error which accounted for the third most common adverse event reported to the National Treasury Management Agency (NTMA) in 2012 (NTMA 2013). Medication errors contributed to post discharge complications and increased general practitioner visits and A&E visits.

In examining research from the United States, Dr. Phelan pointed out that medication error was the most common cause of post discharge complications, accounting for two-thirds of all post operative complications and more than half of these were likely preventable. Medication error accounted for 3.5 million physician office visits, an estimated one million emergency department visits and about 125,000 hospital admissions. Of specific concern were anti coagulants, diabetes agents and opioids, which could lead to significant side effects when medication error occurred. In particular, older people were at higher risk of being prescribed inappropriate medications which were contraindicated for age or prescribed in the wrong dose for their age(Office of the Assistant Secretary for Health 2013)

Of the 6,017 medication related adverse events reported to the NTMA in 2012, incorrect medication on admission/discharge/transfer accounted for 21.8 per cent of the total.

Dr. Phelan said that of the 6,017 medication related adverse events reported to the NTMA in 2012, incorrect medication on admission/discharge/transfer accounted for 21.8 per cent of the total, incorrect discharge accounted for 14.6 per cent, missed medication for 12.4 per cent and incorrect medication for 9.4 per cent.

International literature (Aronson 2009, Office of the Assistant Secretary for Health 2013) concurred with Irish findings as medication error could stem from multiple issues such as inappropriate choice of medicine, errors in writing the prescription, manufacturing errors, dispensing errors, administration errors and a failure to monitor medication impact and medication optimisation.

The literature had also demonstrated that staff working overtime, low staff support and low job security contributed to the increased risk in medication errors, while depression, exhaustion, initial rotation change were particular risk issues for doctors (Aronson 2009). One survey based study of 56 healthcare professionals on the issue of medication errors (Sarvadikar et al, 2010) indicated that nurses and pharmacists were more likely to report such errors, but were also more likely to believe they would be blamed and criticised for the errors. Nurses in this study identified that they could be subject to disciplinary action, while doctors and pharmacists saw this only as a pathway if the medication error was serious. Thus, such fear of repercussions could contribute to lower levels of formal reporting.

In combatting medication error, Dr. Phelan cited research in the area by Chambers et al (2007) which suggested that risk management should focus on eliminating issues such as out of date clinical practice, a lack of continuity of care, poor communication, acknowledge and anticipate known and unknown mistakes in patient care, attend to patient complaints, control financial risk, eliminate concern about reputations and repercussions and counteract low staff morale. Dr. Phelan said that reporting of adverse incidents should be encouraged and staff should not fear disciplinary procedures but be supported in addressing medications errors and other adverse events. One major impact on addressing errors was the publication of the 2014 Principles of Good Practice in Medication Reconciliation by HIQA, which should be adopted in all care settings.