When patients are damaged in the hospital, problems are not always established to avoid this repetition

Over the past two weeks, the media has reported several cases of grave “adverse events”, where Babies, children AND adult An experienced pity and finally died during care in separate Australian hospitals.

When a grave adverse event occurs, Hospitals study What happened and why, and propose recommendations for reducing the risk of similar damage.

ABOUT 1600 investigations in the field of patient safety They are taken every year. And the rates are high. If it is not well managed, the hospital’s response can intensify the psychological harm to the patient and his family. If the lessons are not pulled out, patients’ safety will not improve.

Despite three decades of joint effort, the indicator of adverse events remains stubbornly high in Australia. One in ten people will be get the damage related to hospital care.

What can you do to reduce this damage? There is no quick repair, but our research shows that improving hospital research can have a great impact. Here’s how you can do it.

What exactly are “adverse events”?

Thirty years ago, one of the first on a gigantic scale of patient damage indicators in Australian hospitals was published Quality in Australian healthcare.

Along Further research in other countrieshe found one in ten hospital parties They were associated with an “side event”. They included:

• Drug incidents (such as administration of an incorrect dose or medicine)

• Hospital grip infections (associated with surgery or intravenous lines)

• Deterioration of physical or mental health, which is not detected and managed in a timely manner.

Some adverse events can lead to patients suffering from grave or enduring physical disability and Psychological trauma.

Clinics involved in such events may also suffer Significant mental anxiety and regret.

How are the studied?

When a grave adverse event occurs, hospitals form a team to take Investigation on patient safety. Team experts utilize clinical specializations involved in an undesirable event (such as a rescue department or surgery) and health safety staff.

The investigation also informs “Open disclosure” – information for the patient and the family about why an adverse event took place and what changes he intends to introduce to prevent a similar adverse event.

But ours tests It showed that most of the recommendations in these studies would not reduce damage to patients.

The complexity of healthcare, labor strength and wider pressure on the healthcare system (such as an aging population requiring more sophisticated care) often works for health services effectively implementing recommendations.

So what can you do?

We take tests With four state and territorial rule (Modern South Wales, Wiktoria, Queensland and Australian territory of the capital) to test these strategies and inform how they can be redesigned for safer care. Here’s what we have found so far.

A well -recognized problem with some investigations are them No specialist specialist knowledge in patient safety. In this field they are supported by solid research, but often people undertaking research are experts in their clinical field or in the hospital, but not in security sciences.

In addition, the complexity of healthcare means that the task of finding factors that contributed to damage and developing effective recommendations is even more tough.

Take into account the contrast with biomedical sciences, such as developing up-to-date drugs or tests. They utilize gigantic, specialized, independent research institutions with highly trained scientists. However, the problems of patients’ safety, which are probably sophisticated, are to be solved using a fewer resources, using incomplete staff with variable experience and specific training for the task in a local hospital.

Sophisticated patient safety problems require appropriate investments in specialist knowledge and independence.

Investigations Usually you can’t share. This means that learning remains local. In many hospitals you can conduct repetitive studies of the same type of adverse event, duplicate.

Greater sharing of undesirable events by hospitals and health departments would reduce duplication and would raise the efficiency of science. Aviation does it well. If a commercial jet experiences a problem or close to Miss, this problem is made available so that every airline knows about it.

If we did this, we could prescribe hospital systems to support safer care. This may include, for example, Standardization of the method of drug informationsuch as the dose, it is displayed in all hospital computer systems. Doctors leaving one hospital to another less often make mistakes in prescribing medicines, which is a common risk of patient safety.

Thirty years after the first notification of unwanted events in Australia, patients and a wider society deserve to find out that the research is carried out effectively and the strategies are accepted to ensure the safety of each visit to the hospital.

Read more: Action on the wrong part of the body – what can you do to prevent it?