Project Background

Page contents: Patient Safety Timeline | Prevalence of adverse events | Why collect more than just sentinel or extreme severity adverse events? | References

Patient Safety Timeline
	2001/02 - Sentinel Event Program Established Following the publication of 'Improving Public Safety in Victorian Hospitals'(1), the sentinel event program was established to mandate reporting of 8 nationally endorsed sentinel event categories plus a 9th category called ‘other’. This program continues today.
	2003/04 – Open Disclosure Pilot Project Following the publication of 'Open Disclosure: A national standard for open communication in public and private hospitals following an adverse event in health care'(2), the Victorian pilot project commenced from early 2004 and since then, education sessions have been conducted with all pilot sites. The Australian Commission on Quality and Safety is currently evaluating the national project and timeframes.
	2004 – National Reporting of Sentinel Events In April 2004, the Australian Health Ministers decided that all states and territories would contribute to a national report on sentinel events. Since this time, data has been collected and the first public report is currently been finalised. It is expected for release in late 2006.
	2005 - Auditor Generals Report: Managing Patient Safety in Public Hospitals In early 2005, The Auditor General conducted a review of the effectiveness of the arrangements Victoria’s health services and hospitals have in place to identify, investigate, address and prevent clinical incidents. The review was based on a survey administered to 5 public hospitals. The report concluded “ there is no statewide picture of the nature and number of adverse events and near misses in Victorian hospitals. While sentinel events are reported to DHS…they are only a small fraction of all clinical incidents. As a result, their value in identifying emerging issues, and for trend analysis, is limited”(3) The review found that whilst hospitals are gathering data about clinical incidents locally, the absence of a consistent statewide dataset means that it is not possible to collate this body of information and identify statewide patterns and trends. The report is available from the Auditor General Victoria website.
	2006 – Incident Information System (IIS) Project Established Subsequent to Auditor General findings, the IIS project was initiated in the second quarter of 2006 within the Quality and Safety Branch, DHS.

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Prevalence of Adverse Events

It is generally accepted that adverse outcomes arise through accidents and errors in healthcare and they contribute a significant human and financial burden to society. A decade ago, the Quality in Australian Health Care Study (QAHCS) calculated the national rate of adverse events to be as high as 16%.(4) In Victoria, a recent prevalence and costing study calculated a lower rate of 6.9% for the 2003/04 year with associated costs of $511 million for that financial period. Depending on methodologies and definitions of ‘adverse event’ used, study findings differ, however the fact that approximately 1 in 10 patients experience an unintended injury or complication when in hospital that is not directly associated with their disease, indicates that there is much room for improvement in patient safety.

Why collect more than just sentinel or extreme severity adverse events?

We can’t fix what we don’t know about

High severity incidents (Level 1) that impact patients/clients/residents are currently being reported to the department through the Sentinel Event Program, Statewide Quality Branch. However there is no mechanism to pool lower severity incident data across the state due to variation in classification schemes and severity rating methodologies used from one health service to another. This variation was confirmed via the release of an incident reporting practices survey to all 88 acute health services in July 2006 (92% response rate).

We know through previous data collections that common adverse events include falls and pressure ulcers. Projects have been initiated by both the department and health services to target these adverse events. It is possible however that there are other adverse events not yet considered commonly problematic because at a local health service level they may be considered ‘rare’. However if data can be aggregated at a state wide level, the impact of these events to society may be deemed far more significant.

Research has shown that whilst it is important to capture very serious events, it is also important to capture and target quality improvement initiatives toward lower severity incidents which comprise the bulk of all adverse outcomes in health services and may often be precursors for serious adverse events. A 2002 Australian study which examined the adverse events included in the QAHCS study found that 60% of resource use was attributed to events that led to minor disability, 36% to adverse events that led to major disability and 4% to those associated with death.

The study concluded that attention must be directed to adverse events with both major and minor outcomes, and large scale collection of incidents and adverse events are required to characterise individually rare events(5).

The World Alliance for Patient Safety, a subsidiary of the World Health Organisation (WHO) have worked with Professor Lucian Leape of Harvard School of Public Health to develop a set of guidelines for adverse event reporting and learning systems.

The guidelines note that unless adverse events and results of an analysis are reported to an external organisation, the lessons learned are trapped within the walls of an organisation. Alternatively, if the event is reported and the findings from the investigation are entered into a database, the event can be aggregated with similar incidents to elucidate common underlying causes. A variety of solutions could emerge.(6)

References

1. DHS (2000), Improving Patient Safety in Victorian Hospitals, Department of Human Services, Victoria.
2. Safety and Quality Council (2003), Open Disclosure: A national standard for open communication in public and private hospitals following an adverse event in health care, Commonwealth of Australia.
3. Auditor General Victoria: Managing Patient Safety in public hospitals.
4. Wilson R Mc, Runciman WB, Gibberd RW, et al. (1995) The Quality in Australian Health Care Study, Med J Aust 1995; 163; 458-71
5. Runciman, WB. Edmunds, MJ. Pradhan, M. (2002) Setting Priorities for Patient Care Qual Saf Health Care 2002; 11: 224-229.
6. WHO (2005) WHO Draft Guidelines for Adverse Event Reporting and Learning Systems

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