Adverse Events in Healthcare

Keeping patients safe from harm is the key priority of healthcare organizations. Harm can befall a patient during transit to a hospital or care facility, while waiting for assessment and treatment in the facility, or during a stay in a ward or treatment room. Adverse events in healthcare occur when the “boundary of acceptable performance” (Rasmussen, J. (1997). Risk management in a dynamic society: A modelling problem. Safety Science, 27(2/3), 183–213.) has been crossed. That is, a near miss has not been addressed the first time, and now a second near miss is pushing the organization beyond its ability to cope and keep patients safe. An adverse event may be caused by a number of clinical, human, or systemic/cultural factors. If a near miss or incident goes unreported, chances are that a similar incident will occur later on and may have even more serious consequences. Hence, staff are encouraged to report a near miss, even if they are fearful that they may be reprimanded. Cultural change is required to create a psychologically safe environment in which staff are keen to report incidents so they can learn from their mistakes. When coaching services are available to leaders and clinical team members, they learn how to become more observant so that incidents occur less frequently. Leaders learn how to provide constructive feedback to staff which encourages them to pay more attention to improving their clinical practice. Safety-11 (Hollnagel, E., Wears, R., & Braithwaite, J. (2015). From safety-I to safety-II: A white paper. University of Southern Denmark, University of Florida, Macquarie University.) clinical practices focus on doing more of what is going right to identify excellence, rather than looking backward at what could have or should have been done to prevent an incident from occurring.