What Can Be Done to Reduce Harm in Australian Hospitals?

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.

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

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.

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.

Improving hospital investigations

Our research has shown that improving hospital investigations can have a big impact. Here are some strategies that can be employed:

* Ensure that the investigation is led by a team with expertise in patient safety, rather than just clinical or hospital management.
* Standardize the investigation process and templates to ensure consistency across all hospitals.
* Encourage sharing of adverse events between hospitals to reduce duplication of effort and improve learning.
* Invest in training and resources for hospital staff to ensure they have the necessary skills to conduct effective investigations.

Conclusion

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. With the right approach, we can reduce the number of adverse events and improve patient safety.

FAQs

* What is an adverse event?
+ An adverse event is a serious harm or injury to a patient that occurs while they are receiving care in a hospital.
* How common are adverse events?
+ One in ten people will experience harm associated with their hospital care.
* What can be done to reduce harm in hospitals?
+ Improving hospital investigations, standardizing the investigation process, sharing adverse events between hospitals, and investing in training and resources for hospital staff.
* How can we improve hospital investigations?
+ Ensure that the investigation is led by a team with expertise in patient safety, standardize the investigation process and templates, and encourage sharing of adverse events between hospitals.