Adverse Events in Healthcare

According to Chapter 11 of The Health Care Quality Book, the goal of patient safety in health care is for no patient to experience “unnecessary harm, pain, or other suffering” (Ransom, Joshi, Nash, and Ransom, 2008, p. 244). The book defines a patient’s personal experience of injury or harm resulting from a medical event as an adverse event. This is why the perspective of the patient is the most important determinant as to whether an adverse event has occurred.

Adverse events can be caused by human errors, such as administering to a patient the wrong type or wrong dosage of medicine, resulting in harm coming to the patient. These errors can also occur and not be adverse events in the case of the error not causing any harm to the patient. An example of an error not causing an adverse event could include the administration of the wrong medicine to a patient when the error is caught before the patient ingests the medicine. While an error was still made, no harm came to the patient and the patient still views the care as satisfactory.

Alternatively, adverse events can be caused by the nature of a surgery or procedure with widely known or common complications. For example, in a surgery with common complications that do not derive from human error, an adverse event can occur even if the surgeons, doctors, and nurses perform their duties perfectly.

When an adverse event occurs, such as the death of a patient, there is always someone who wants to assign blame. It is unfortunate that this often leads doctors to lawyer-up in preparation for a malpractice lawsuit. In class, it was discussed that very often the families of the deceased simply want an explanation and apology from those responsible, not a lawsuit; however, an explanation and apology can be seen as an admission of guilt and can potentially be used against the defendants in court. I wish there could be more of a culture of learning from mistakes instead of hiding them so that others could learn from them and hopefully decrease their frequency.

Ransom, E. R., Joshi, M. S., Nash, D. B., Ransom, S. B. (2008). The health care quality book: Vision, strategy and tools (2^nd ed.). Chicago, IL: Health Administration Press.

My Grandmother and Nursing Home Care

            After my grandmother, Estelle, broke her hip just over two years ago, it wasn’t long before talk of finding a suitable nursing home came to be a common topic of conversation between my parents. At 91 years old, she was one of the oldest inhabitants at her apartment community for “active seniors” in West Palm Beach and it was no surprise to any of her friends and neighbors that the time would soon come for her to need more help.

            Just after surgery and a few months in a rehabilitation facility, Estelle was ready to move to a long-term care nursing home. In anticipation of this move, my family had put her name on a waiting list at a few nursing homes in her area; however, when the time came for her to leave the rehabilitation center there were still no open spots available. My family panicked at the thought of Medicare ending payment to the rehabilitation facility and us having to pick up the astronomical bill for a prolonged residency while we waited for a bed to open. The wait was excruciating for both my grandmother and my parents as beds came and went due to management’s confusion and incompetent staff whose correspondence with Medicaid made the wait that much harder. 

            Finally, we decided that my grandmother should move to an Orlando nursing home so we could more easily advocate for her care from a greater proximity. While waiting for an open bed at a local nursing home, the director of the facility kept in constant contact with my family to update us on the status and presumed availability of new beds. The director’s personable nature really helped my family to see the facility as one that really cared about its patients and their families. One day, a staff member alerted my parents to a bed that would be ready in the coming week, yet when the director called to give us more information, we learned that he did not think the roommate would be a good match for my grandmother because the woman had a long history of past roommate troubles. Unlike stereotypical nursing home directors, anxious to fill beds, this director seemed to care more about my grandmother’s well-being. 

            Once a suitable bed opened up and my grandmother entered the facility, we were pleasantly surprised at the quality of care present in the nursing home. The staff always seemed to be friendly and helpful, something Estelle loves. Additionally, a nurse always responds to our calls and concerns in a timely manner. My parents have even had numerous phone conversations with my grandmother’s main doctor over our wishes to provide her with dietary supplements that were not prescribed by one of her doctors. The physician’s willingness to work with us made my grandmother’s transition into the nursing home as easy as could be. 

            What worries me, however, is the quality of care provided to patients who do not have strong advocates, such as parents like mine. Estelle’s roommate, Mercedes, is one of those patients. Although Mercedes’ daughter lives less than an hour away, she is rarely present for Mercedes’ medical appointments and to oversee treatment. Although her quality of care seems to be good, there have been instances where my father has had to step in and speak with a doctor on her behalf due to her inability to know what is best for her. It seems that there should be an advocate, independent of the nursing home, available to provide information to patients and act on their behalf on a daily basis. These advocates would provide assistance to those patients who may have trouble asking for help on their own.