Role of Miscommunications in Adverse Events

Ailsa Haxell, Terry Weblemoe, Alex BowmarSchool of Interprofessional Health Studies

Faculty of Health and Environmental Sciences

Adverse events (AE)Is generally defined as:1) an unintended injury2) resulting in disability, and 3) caused by healthcare management rather

than the underlying disease process(Davis et al, 2003)

Adverse event rates

(Kohn, Corrigan & Donaldson, 1999)

Country Author & year AE rate (as%) AE deaths (%)

USA Kohn et al., 1999 2.9-3.7 2.9 - 6.6

Australia Wilson et al., 1995 16.6 51

Canada Baker et al., 2004 7.5 20

England Vincent et al., 10.8-11.7 48

Netherlands Zegers et al., 2009 5.7 12.8

New Zealand Davis et al., 2002 11.2 15

Equivalent to 4 Boeing 747 crashes every year (Evans, 2007)Image cc licence https://upload.wikimedia.org/wikipedia/commons/7/7d/CID_post-impact_1.jpg

3x the death rate from motor vehicle accidents (Evans, 2007)Image cc licence http://www.teara.govt.nz/en/road-accidents

DALY:a measure of fatal and non-fatal impacts combined as a measure of health loss

(MOH, 2013)

IatrogenesisThe adverse and unintended outcomes of health service delivery.

(Illich, 1975)

• Incident reporting is largely restricted to in hospital care, and limited to physical harm • (See for example Brennan etal, 1991; Wilson et al., 1995; Kohn, Corrigan & Donaldson,

1999; Thomas et al., 2000; Vincent, Neale & Woloshynowych, 2001; Davis et al., 2002; Baker et al., 2004; Zegers et al., 2009)

• Provider capture? Records of adverse events are most commonly the result of incidents as reported by health professionals (Harrison .et al., 2015).

• Little correlation (0.4%) between adverse events reported by patients to Health and Disability Commissioner and those documented by health professionals. This increases to just 4% when reviewing those classified as serious and preventable (Bismark et al., 2006).

Documentation of adverse events is but the tip of an iceberg

Country Author, year Preventable AE % Recommendation

USA Kohn et al., 1999

27.6 - 76 Non punitive reporting Standardize & simplify processes interdisciplinary team trainingImprove medication systems

Australia Wilson et al., 1995

51.2 Improve systemsInadequate reportingAverse to blaming individuals

Canada Baker et al., 2004

36.9 Improve medication safetyModify work environmentLeadershipImprove reportingImprove coordination Improve communication

England Vincent et al., 48 Not discussed

Netherlands Zegers et al., 2009

39.6 Organisational Review surgical procedures

New Zealand Davis et al., 2002

Improve systemsConsultationEducation

We thought the data was a little old.We wanted to know if there had been improvementReview of the literature:The more recent literature is questioning the accuracy of the data reported, the definitions of AE,the data collecting, the limitations of coding…

and the absence of a consumer voice.

An alternative narrative we “listened” to recipients of health servicesImage: Authors own

Method: Stage 1*: We reviewed 100 case studieson the HDC website (April 2013-April 2014)

Interim Findings: • In these case studies, healthcare is not

geographically bound by hospitals.• Definitions of harm are markedly different to those

attended to in previous studies of adverse events. • Harm extends to mental, spiritual, emotional,

relational, sexual, financial as well as physical harm.

* Stage2 (in process) – reviewing all case studies from 2012 to current using NVivo coding software, coding for adverse events, range of health professionals involved, site of health care service provision, as well as for the range of miscommunication contributing to adverse events.

Further findings: Recipients of healthcare, at least in these case studies, tend not to talk of system failure, or better surgical procedures, or medication systems, or improving the reporting of adverse events….

In ninety-nine out of hundred case studies, it is miscommunications that are implicated.

We are loathe to accept that:Iatrogenesis is compounded by the inability of those within the established institutions of health service delivery to critically consider the harm that they perpetuate (Illich, 1975).

And therefore ask: “What could we, should we, will we, do?”

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