Thesis on the causes of unintended events in hospitals
Several patients suffer from adverse events as a result of the care they received in the hospital. On November 23rd – in the Dutch week of patient safety – NIVEL-researcher Marleen Smits will defend her thesis on the causes of such unintended events at the VU University Medical Center in Amsterdam.
Patient safety
Previous research of NIVEL and EMGO+ has shown that in 5,7% of all hospital admissions, patients experience an adverse event. Forty percent of these adverse events is potentially preventable. The percentages are based on a national study of patient records, that was published in 2007. “This record review study gave us the opportunity to study the causes of adverse events as well”, says Marleen Smits. “It is important to know not only how often things go wrong, but also because of what they go wrong. To improve patient safety, the root causes have to be tackled.”
A group of trained physicians reviewed patient records and in case of an adverse event, they judged whether the adverse event was caused by human, organisational, technical or patient related factors. Often, several causes were involved simultaneously in one adverse event. In more than half of the adverse events, human causes were involved. For example, when a professional misjudged the state of the patient or did not verify if all necessary materials and instruments were present before starting the intervention.
PRISMA root cause analysis
An additional study was performed using event reports from healthcare professionals in surgery, internal medicine and emergency medicine departments. Professionals were asked to report all events that were unintended, irrespective of whether the event had consequences for the patient. The causes of the unintended events were analysed with PRISMA, a method that unravels the unintended events in various root causes by means of constructing a ‘causal tree’. An inter-rater reliability study showed the method is reliable. “Hospital staff can use PRISMA by themselves”, says Smits.
In this study, the majority of causes was classified as human too, but in many cases there was a combination of human causes with causal factors in the working environment (technical and organisational). Smits: “Therefore, it is important to direct interventions on the system that surrounds people. Just giving extra training or motivating personnel will not improve patient safety. Fortunately, this is taken up by the Dutch safety programme ‘Prevent harm, work safely’, in which hospitals follow action plans on ten themes with high risks.”
Methods
The causes of unintended events were examined using a record review study in 21 hospitals (7926 patient records) and a study on event reports of healthcare professionals at 28 units in 19 hospitals (1885 event reports). The study was carried out by NIVEL and the EMGO Institute for Health and Care Research and was initiated by the Dutch Society of Medical Specialists (in Dutch: Orde van Medisch Specialisten) with financial support from the Ministry of Health, Welfare and Sport.
Expert/contact
Marleen Smits, 030 272 97 00