Adverse Events

Definition

Adverse events are defined by the Washington State Department of Health (State DOH) as medical errors that could and should have been avoided by health care facilities. These errors, called Serious Reportable Events as defined by the National Quality Forum (NQF), may result in patient death or serious disability. Health care facilities must report to the State DOH when any of these 28 errors occur.

Washington State Law

In 2006, the Washington State Legislature passed Chapter 70.56 Revised Code of Washington (RCW), Adverse Health Events and Incident Reporting System. The goal of this law is to learn why events happen and what can be done to prevent them from happening again.  Providers required to report include hospitals, psychiatric hospitals, child birth centers, Department of Corrections’ medical facilities, and ambulatory surgery facilities. Each health care facility must then review the event (see Root Cause Analysis section below) and develop an action plan to help prevent reoccurrence.  Reports must be filed at least every three (3) months whether a facility has experienced an adverse event (or not).  If the facility does not file a report, they will be contacted by the State DOH. 

The reporting law is meant to enhance accountability and transparency. By sharing adverse events and their causes, policymakers hope to foster a culture of  The State DOH Adverse Events website includes useful information on identifying and reporting an adverse event and steps to take after that report. 

Steps to Identify, Report, and Follow up an Adverse Event

Step 1: Identifying an Adverse Event

How do I tell if a particular event meets the criteria of an “adverse event”?  One of the useful tools on the State DOH website is a decision tree that can help define whether an event is an “adverse event” or not.  Compare the event to the list of 28 adverse events.  Does it fit these criteria or not?  If you believe patient or staff safety are at risk or there has been harm, err on the side of reporting rather than not reporting – this may save someone from injury or death in the future! 

Adverse Events in Washington State

The State DOH published reports of adverse events.  These can be accessed by type of events, facility by quarter, facility by event, facility by date, along with additional information (Contextual Information reports).  This includes an annual report, which breaks out adverse events by type for the past year.  According to the report published in 2010, the events most frequently reported for June 2006 to September 2009 were:

Total of 652 Events

• Pressure Ulcers – 342 or 52%
• Surgical Events – 192 or 29%
• Falls – 49 or 8%
• Medication Errors – 18 or 3%
• Other Adverse Event Types – 51 or 8%

The Washington State Hospital Association looked at reported adverse events for selected Washington State Hospitals.  Of 100 events reported by 10 hospitals, there were 19 Falls, 45 Pressure Ulcers (including ulcers caused by respiratory devices such as nasal cannulas, masks, and tracheostomy tubes), 26 surgical events (broken out into 15 incorrect surgeries and 11 retained foreign objects), 8 unanticipated deaths, and 7 other adverse events.  The surgical events were all related to procedures done in units such as Labor and Delivery, Imaging, and at the Patient’s Bedside and did not occur in the operating room!

Step 2: Filing a Complaint/Reporting an Adverse Event

Complaint forms are available on the DOH website.  This includes forms for: Health Professionals, Health Facilities, Hotels/Motels, Nursing Professionals, and Physicians and Physician Assistants.  There are also other useful links, including a link for Medicare patients to file a complaint with the Centers for Medicare & Medicaid.  There is also contact information on this page if you have any questions.

Step 3: After Reporting an Adverse Event

Root Cause Analysis (RCA)

Each adverse event notification requires a “Root Cause Analysis.” This is a system-based review of a medical error in which the department explores what happened, why it happened, and the facility plans so that the event can be prevented from happening again.  If you are not familiar with conducting a root cause analysis, there are a number of documents available on the State DOH website for reference.  A particularly useful tool is a step by step guide through the Root Cause Analysis process.
In the WSHA study of adverse events, the most frequently cited underlying causes of the events were:

• Failures in communication during handoffs
• Unclear communication in critical situations
• Lack of protocols
• Lack of knowledge of products or unavailability of equipment
• Ineffective education

System issues that are noted in many of the RCA’s include a culture that has failed to support and communicate patient safety, failure in the chain of command, and discipline silos.  It was also noted that the causes of pressure ulcers and falls shared many risk factors in common.  While there are multiple interventions available to prevent pressure ulcers and falls, they must be selected with the individual patient in mind.  For example, pressure relieving mattresses may increase the risk of fall as they are very slippery.  It was also noted that communication with family and significant others and education are important as they may try to assist the patient – for example, getting the patient up to the bathroom. 

Using Results of RCA to Improve

Based on the finding of the RCA, steps should be taken to prevent the adverse event from happening again.  Most adverse events happen because of a series of system errors, not just an error on the part of one individual.  Learning from the findings helps to involve staff at every level in being aware of patient and staff safety. 
In 2009, the NQF published “Safe Practices for Better Healthcare – a 2009 Update”.  Applying these practices across an organization can help to improve care for everyone. 
Other suggestions include:

• Identify common causes of adverse events
• Standardize protocols/interventions
• Identify measureable culture of safety improvements – Just Culture, “no blame”
• Develop specific checklists/other preventive measures
• Learn, educate, inform, and collaborate around Patient Safety