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Medical Care Safety - Problems and Perspectives

  • Yuriy Voskanyan
  • Irina ShikinaEmail author
  • Fedor Kidalov
  • David Davidov
Conference paper
Part of the Lecture Notes in Networks and Systems book series (LNNS, volume 78)

Abstract

The article presents modern views on the essence of the term “medical care safety”, and describes the relevance of the topic, systemic approaches to adverse event risk management in medicine. The authors consider the term “medical care safety” as the ratio of the benefit for the patients and the risk of harm to the patient and medical staff, as well as the risk of unfavorable changes in the internal and external environment. Additional harm related to medical care (adverse events) is observed in 10.6% of hospitalized patients. Medical errors, as a cause of preventable harm, account for 45.5% of cases, other adverse events are classified as unpreventable. The cumulative probability of severe harm among patients with medical care-related complications is 11.8%, of unexpected death – 5.3%. Deaths due to adverse events account for 24.9% of hospital mortality and 9.7% of population deaths. High percentage of deaths unrelated to the progression of the underlying disease and comorbidities allows the authors to define medical care as a high-risk type of services. Systemic causes of medical care-related additional harm are latent threats that are constantly present and subsequently transformed into incidents and adverse events at the level of medical staff, patients and the environment in which medical care is provided. Identification of all latent threats and subsequent management of their transformation is the basis of the modern strategy of medical care safety management. It is impossible to ensure high level of safety in medical facilities without formation of a new culture not only at the level of an individual medical facility but also at the level of the government, the entire medical care system and the society.

Keywords

Medical care safety Adverse events Incident Unexpected death 

References

  1. 1.
    Roitberg, G.E., Kondratova, N.: Medical Organization According to the International Quality Standards: A Practical Guide to Implementation, 152 p. Moscow (2018) (In Russia)Google Scholar
  2. 2.
    World Health Organization: World Health Statistics: Monitoring Health for the SDGs, Sustainable Development Goals. Geneva. http://www.who.int/gho/publications/world_health_statistics/2018/en/ (2018)
  3. 3.
    Brennan, T.A., Leap, L.L., Larid, N.M., et al.: Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N. Engl. J. Med. 324, 370–376 (1991)CrossRefGoogle Scholar
  4. 4.
    Wilson, R.M., Runciman, W.B., Gibberd, R.W., et al.: The quality in Australian medical care study. Med. J. Aust. 163, 458–471 (1995)CrossRefGoogle Scholar
  5. 5.
    Thomas, E.J., Studdert, D.M., Burstin, H.R., et al.: Incidence and types of adverse events and negligent care in Utah and Colorado. Med. Care 38(3), 261–271 (2000)CrossRefGoogle Scholar
  6. 6.
    Vincent, C., Neale, G., Woloshynowych, M.: Adverse events in British hospitals: preliminary retrospective record review. BMJ 322(7285), 517–519 (2001)CrossRefGoogle Scholar
  7. 7.
    Schioler, T., Lipczak, H., Pedersen, B.L., et al.: Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskr Laeger 163(39), 5370–5378 (2001)Google Scholar
  8. 8.
    Davis, P., Lay-Yee, R., Briant, R., et al.: Adverse events in New Zealand public hospitals I: occurrence and impact. NZMJ 115(1167), U271 (2002)Google Scholar
  9. 9.
    Baker, G.R., Norton, P.G., Flintoft, V., et al.: The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ 170(11), 1678–1686 (2004)CrossRefGoogle Scholar
  10. 10.
    Zegers, M., Bruijne, M.C., Wagner, C., et al.: Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual. Saf. Med. Care. 18, 297–302 (2009)CrossRefGoogle Scholar
  11. 11.
    Landrigan, C.P., Parry, G.J., Bones, C.P., et al.: Temporal trends in rates of patient harm resulting from medical care. N. Engl. J. Med. 363, 2124–2134 (2010)CrossRefGoogle Scholar
  12. 12.
    Classen, D.C., Resar, R., Griffin, F., et al.: «Global trigger tool» shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff. 30, 4581–4589 (2011)CrossRefGoogle Scholar
  13. 13.
    Deilkås, E.T., Bukholm, G., Lindstrøm, J.C., Haugen, M.: Monitoring adverse events in Norwegian hospitals from 2010 to 2013. BMJ Open 5, 1–6 (2015)CrossRefGoogle Scholar
  14. 14.
    Andrews, L.B., Stocking, C., Krizek, T., et al.: An alternative strategy for studying adverse events in medical care. Lancet 349(9048), 309–313 (1997)CrossRefGoogle Scholar
  15. 15.
    Wanzel, K.R., Jamieson, C.G., Bohnen, J.M.A.: Complications on a general surgery service: incidence and reporting. CJS. 43(2), 113–117 (2000)Google Scholar
  16. 16.
    Szlejf, C., Farfel, J.M., Curiati, J.A., et al.: Medical adverse events in elderly hospitalized patients: a prospective study. Clin. (Sao Paulo). 67(11), 1247–1252 (2012)CrossRefGoogle Scholar
  17. 17.
    McGuire, H.H.J., Horsley, J.S., Salter, D.R., Sobel, M.: Measuring and managing quality of surgery. Statistical vs incidental approaches. Arch. Surg. 127(6), 733–737 (1992)CrossRefGoogle Scholar
  18. 18.
    O’Neil, A.C., Petersen, L.A., Cook, E.F., et al.: Physician reporting compared with medical-record review to identify adverse medical events. Ann. Intern. Med. 119(5), 370–376 (1993)CrossRefGoogle Scholar
  19. 19.
    Singh, H., Spitzmueller, C., Petersen, N.J., et al.: Primary care practitioners’ views on test result management in EHR-enabled health systems: a national survey. J. Am. Med. Inform. Assoc. 0, 1–9 (2012)Google Scholar
  20. 20.
    Woods, D.M., Thomas, E.J., Holl, J.L., et al.: Ambulatory care adverse events and preventable adverse events leading to a hospital admission. Qual. Saf. Med. Care. 16(2), 127–131 (2007)CrossRefGoogle Scholar
  21. 21.
    Leap, L.L., Brennan, T.A., Nan Laird, M.P.H., et al.: The nature of adverse events in hospitalized patients. Results of the Harvard medical practice study II. N. Engl. J. Med. 324, 377–384 (1991)CrossRefGoogle Scholar
  22. 22.
    Andrews, J.M., Remon, C.A., Burillo, J.V., Lopez, P.R.: National Study on Hospitalisation-Related Adverse Events ENEAS 2005. Quality Plan of National Health System. Report. http://www.who.int/patientsafety/information_centre/reports/ENEAS-EnglishVersion-SPAIN.pdf, February 2006. Access 7 July 2018
  23. 23.
    Campbell, M.J., Jacques, R.M., Fotheringham, J., et al.: Developing a summary hospital mortality index: retrospective analysis in English hospitals over five years. BMJ 344, 1001–1012 (2012)CrossRefGoogle Scholar
  24. 24.
    Wilson, L., Ferguson, C., Hider, Ph., et al.: Perioperative Mortality in New Zealand: Fourth Report of the Perioperative Mortality Review Committee. Report to the Health Quality & Safety Commission New Zealand. http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1424-30-october-2015/6712, June 2015. Access 7 July 2018
  25. 25.
    Hospital Trends in Canada. Canadian Institute for Health Information. National Health Expenditure Database. 2005 Ottawa, Ontario. https://secure.cihi.ca/free_products/Hospital_Trends_in_Canada_e.pdf. Access 7 July 2018
  26. 26.
    Aiken, L.H., Sloane, D.M., Bruyneel, L., et al.: Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 26, 1–7 (2014)Google Scholar
  27. 27.
    Jarman, B., Pieter, D., van der Veen, A.A., et al.: The hospital standardised mortality ratio: a powerful tool for Dutch hospitals to assess their quality of care? Qual. Saf. Med. Care. 19, 9–13 (2010)CrossRefGoogle Scholar
  28. 28.
    Makary, M.A., Daniel, M.: Medical error—the third leading cause of death in the US. BMJ 353(3), 1–5 (2016)Google Scholar
  29. 29.
    Hall, M.J., Levant, S., De Frances, C.J.: Trends in inpatient hospital deaths: national hospital discharge survey, 2000–2010 (U.S. DHHS - Centers for Disease Control and Prevention), 118. NCHS Data Brief. March 2013Google Scholar
  30. 30.
    Beuzekom, M., Boer, F., Akerboom, S., Hudson, P.: Patient safety: latent risk factors. Br. J. Anaesth. 105(1), 52–59 (2010)CrossRefGoogle Scholar
  31. 31.
    Lawton, R., Carruthers, S., Gardner, P., et al.: Identifying the latent failures underpinning medication administration errors: an exploratory study. Health Serv. Res. 47(4), 1437–1459 (2012)CrossRefGoogle Scholar
  32. 32.
    Reason, J.: Human error: models and management. Br. Med. J. 320, 768–770 (2000)CrossRefGoogle Scholar
  33. 33.
    Hoffmann, B., Rohe, J.: Patient safety and error management. Dtsch. Arztebl. Int. 107(6), 92–99 (2010)Google Scholar
  34. 34.
    Mitchell, R., Williamson, A., Molesworth, B., Chung, A.: A review of the use of human factors classification frameworks that identify causal factors for adverse events in the hospital setting. Ergonomics 57(10), 1443–1472 (2014)CrossRefGoogle Scholar
  35. 35.
    Carayon, P., Schoofs Hundt, A., Karsh, B., et al.: Work system design for patient safety: the SEIPS model. Qual. Saf. Medical Care 15(Suppl I), 150–158 (2006)Google Scholar
  36. 36.
    Clancy, C., Tornberg, D.: TeamSTEPPS: assuring optimal teamwork in clinical settings. Am. J. Med. Qual. 22(3), 214–217 (2007)CrossRefGoogle Scholar
  37. 37.
    Edmondson, A.: Learning from failure in medical care: frequent opportunities, pervasive barriers. Qual. Saf. Med. Care. 13(Suppl II), 113–119 (2004)Google Scholar
  38. 38.
    Lyons, M.: Should patients have a role in patient safety? A safety engineering view. Qual. Saf. Med. Care 16(2), 140–142 (2007)CrossRefGoogle Scholar
  39. 39.
    Verstappen, W., Gaal, S., Esmail, A., Wensing, M.: Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care. Eur. J. Gen. Pract. 21(Suppl 1), 50–55 (2015)CrossRefGoogle Scholar
  40. 40.
    Molloy, G.J., O’Boyle, C.A.: The SHEL model: a useful tool for analyzing and teaching the contribution of human factors to medical error. Acad. Med. 80(2), 152–155 (2005)CrossRefGoogle Scholar
  41. 41.
    Takayanagi, K., Hagihara, Y.: Revised sunflower-SHELL model–an analysis tool to ensure adverse-events’ factor analysis and followed by patient safety strategy. Jpn. Hosp. 25, 11–18 (2007)Google Scholar
  42. 42.
    Pronovost, P., Weast, B., Holzmueller, C., et al.: Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual. Saf. Med. Care 12, 405–410 (2003)CrossRefGoogle Scholar
  43. 43.
    Lilford, R., Mohammed, M., Braunholtz, D., Hofer, T.: The measurement of active errors: methodological issues. Qual. Saf. Med. Care 12(Suppl II), 118–1112 (2003)Google Scholar
  44. 44.
    Hibbert, P., Williams, H.: The use of a global trigger tool to inform quality and safety in Australian general practice: a pilot study. Aust. Fam. Physician 43(10), 723–726 (2014)Google Scholar
  45. 45.
    Michel, Ph, Quenon, J., de Sarasqueta, A., Scemama, O.: Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ 328(24), 199–202 (2004)CrossRefGoogle Scholar
  46. 46.
    Pietra, L., Calligaris, L., Molendini, L., et al.: Medical errors and clinical risk management: state of the art. Acta. Otorhinolaryngol. Ital. 25, 339–346 (2005)Google Scholar
  47. 47.
    Shaw, R., Drever, F., Hughes, H., et al.: Adverse events and nearmiss reporting in the NHS. Qual. Saf. Med. Care. 14, 279–283 (2005)CrossRefGoogle Scholar
  48. 48.
    Shikina, I.B., Vardosanidze, S.L., Voskanyan, Yu.E., Sorokina, N.V.: Problems of patients’ safety assurance in modern medical care, 336 p. Publishing House Glossarium LLC, Moscow (2006) (In Russian)Google Scholar
  49. 49.
    Joint Commission International Accreditation Standards for Hospitals 6th Edition. Effective. Including Standards for Academic Medical Center Hospitals, 1 July 2017, 37 p. https://www.jointcommissioninternational.org/assets/3/7/JCI_Hosp_Standards_6th_STANDARDS_ONLY_14Jan2018.pdf. Access 7 July 2018
  50. 50.
    Zadvornaya, O.L., Voskanyan, Y.E., Shikina, I.B., Borisov, K.N.: Socio-economic aspects of medical errors and their consequences in medical organizations. MIR (Modernization. Innovation. Research) 10(1), 99–113 (2019).  https://doi.org/10.18184/2079-4665.2019.10.1.99-113 (In Russia)CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Russian Medical Academy of Continuing Professional EducationMinistry of Health of RussiaMoscowRussia
  2. 2.Central Research Institute for Organization and Informatization of Medical CareMinistry of Health of RussiaMoscowRussia
  3. 3.Central State Medical Academy Office of the President of the Russian FederationMoscowRussia
  4. 4.State Government Institution of Moscow City “Informational-Analytical Center” for Medical CareMoscowRussia

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