Patients have reason to fear hospitalization. Researchers found recently that one in 10 hospitalized patients in Britain will be harmed during their stay by “adverse incidents” – a euphemism for sometimes fatal complications that include infections, surgical errors and drug issues. This is not the first look at a long-running problem. The question is whether the new report will be seen as the “last straw,” prompting Britain to be the first country to take action that is comprehensive enough to cut the figures.
University of York researchers focused on a single major acute hospital in England, examining the cases of 1,006 people who were admitted for care. The results were published in the journal, Quality and Safety in Health Care, and picked up by the BBC on November 29.
Eighty-seven people in the study group had definitely suffered at least one adverse event, they said, and it was likely even more had suffered harm. They found 40 infections, 27 complications during or following operations, 19 drug complications, and 12 cases of bedsores. Between 30 percent and 55 percent of the events could have been prevented by clinical staff or managers, according to the researchers.
As examples of preventable incidents they cited a mistake in an operation that led to the death of the patient, another that caused lifelong damage, and a case in which a patient became addicted to painkillers after being given a high dose during and after a hospital stay.
Interviewed by the BBC, Professor Trevor Sheldon, who led the research, said the study confirms “that hospitals are not completely safe places, and … people should try to steer clear of them unless absolutely necessary." He pointed out that the rates show Britain’s National Health Service (NHS) is not faring worse that other bodies. Hospital harm is an international issue and that other countries have similar or worse rates, he explained. “The question we have to ask is whether the NHS is currently doing enough to help people find the time to reflect on these cases and learn lessons from them.”
The professor observed that that the scale of the problem means that more resources should be spent tackling it.
Chief Medical Officer Sir Liam Donaldson told the BBC that improvements have been made across the NHS to embed patient safety into everyday practice. "However, more needs to be done to accelerate the pace of change in this area," he said, adding it is often systems that have failed rather than any individual being at fault.
Comprehensive action would include looking for flaws in work systems and the hospital culture, as well as their effects. The Ergonomics Report®, a publication for readers in ergonomics-related professions, has published several articles on medical errors. One problem frequently implicated is fatigue, often a result of shift patterns that have not built ergonomics into the design. Over-long or poorly-designed shifts can leave hospital personnel worn out and mistake prone.
The researchers suspect the adverse events are more prevalent than their study suggests. They want to see a better reporting system in place.
Sources: BBC; Ergonomics Report®