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.