Limiting risk of hospital adverse events: Avoiding train wrecks is more important than counting and reporting them

Morton, A., Cook, D., Mengersen, K. and Waterhouse, M. (2010) Limiting risk of hospital adverse events: Avoiding train wrecks is more important than counting and reporting them. Journal of Hospital Infection, 76 4: 283-286. doi:10.1016/j.jhin.2010.06.010


Author Morton, A.
Cook, D.
Mengersen, K.
Waterhouse, M.
Title Limiting risk of hospital adverse events: Avoiding train wrecks is more important than counting and reporting them
Journal name Journal of Hospital Infection   Check publisher's open access policy
ISSN 0195-6701
1532-2939
1475-9594
Publication date 2010-12
Sub-type Critical review of research, literature review, critical commentary
DOI 10.1016/j.jhin.2010.06.010
Volume 76
Issue 4
Start page 283
End page 286
Total pages 4
Place of publication London, United Kingdom
Publisher W.B. Saunders Co.
Collection year 2011
Language eng
Abstract Targets implemented at national or state levels have been employed in response to excessive numbers of adverse events (AEs) such as multiple antibiotic-resistant Staphylococcus aureus bacteraemias. Hospital resources are limited and setting such targets can result in resource diversion to dealing with the targeted AEs. There may be initial success as judged by decreasing counts but underlying problems are not necessarily addressed, and there is evidence that other non-targeted AEs may increase. Moreover, the values of individual observations can be greatly influenced by random variation. This can make it difficult using comparisons and targets to draw conclusions about the work of an institution. Although counting AEs is essential, the key to avoiding episodes of patient harm is prevention. This requires the implementation of evidence-based systems. These are already available for many AEs in the form of 'bundles' and checklists. When these systems are properly implemented and sustained, AE rates tend to occur at minimum predictable levels. Unfortunately, in spite of widespread knowledge and aggressive promotion, high levels of compliance have often been difficult to achieve and sustain. Better understanding and implementation of methods to sustain evidence-based systems are needed. Checklists, used as part of an overall system involving leadership and empowerment, application of evidence, culture change and measurement, may help to overcome this problem. © 2010 The Hospital Infection Society.
Keyword Adverse events
Bundles
Checklists
Evidence-based systems
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Critical review of research, literature review, critical commentary
Collections: Faculty of Health and Behavioural Sciences -- Publications
Official 2011 Collection
School of Medicine Publications
 
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Created: Sun, 12 Dec 2010, 00:05:44 EST