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When things go wrong

When we are sick, our care should be of the best quality. We should be safe while treated by health professionals. However, even the best of treatment plans can go wrong.

There are two things that can affect patients health and wellbeing. The first is an adverse event. The second is a treatment injury.  There can be an overlap between adverse events and treatment injuries. Patients who suffer an adverse event may also have a treatment injury. 

The Health Quality and Safety Commission have a definition of an adverse event. 

An adverse event is an event with negative reactions or results that are unintended, unexpected or unplanned (often referred to as ‘incidents’ or ‘reportable events’). In practice this is most often understood as an event which results in harm to a consumer.

Here are some examples of types of adverse events:

  • Delay in escalation of treatment
  • Wrong or unnecessary procedure
  • Procedural injury
  • Medication error
  • Delay/failure in follow up or treatment
  • Other clinical events
  • Falls
  • Hospital Acquired Pressure injury

If one of these event occurs during treatment, it should be reported by the service provider. Under the National Adverse Events Reporting Policy 2017, health and disability service providers with obligations under the Health and Disability Services (Safety) Act 2001, and those who voluntarily comply, are expected to:

  1. report serious adverse events (severity assessment code (SAC) rating 1 and 2) and events on the Always Report and Review list to the Commission, using the adverse event brief – part A reporting form. This report should be made within 15 working days of notification of the event to the provider

  2. undertake formal review of serious adverse events (SAC 1 and 2) and events on the Always Report and Review list and send review findings and recommendations to the Commission, using the adverse event brief – part B reporting form. This report should be made within 70 working days of notification of the event to the provider.

The Health Quality and Safety Commission states, consumers and their whānau who have been involved in the event, should be offered the opportunity to share their story as part of the review process. The review findings and recommendations should be shared with them.

Each year health service providers report to the Health Quality and Safety Commission. You can access the report here.https://www.hqsc.govt.nz/our-programmes/adverse-events/serious-adverse-events-reports/

The Commission takes the view that a reporting process can help improve health safety and quality. The Adverse Events Learning Programme aims to improve consumer safety by supporting organisations to report, review and learn from adverse events that occur in health and disability services. The role of the Programme is to promote a nationally consistent approach to reporting, review and learning. There is a strong desire to share lessons learned nationally and across the health and disability sector.

Examples from 2015/6

  1. A tracheostomy was partially dislodged during transfer to chair. Difficulties in re‐ establishing airway led to lack of oxygen to brain and eventual fatal outcome. A review is still in progress. 

  2. Delay in assessment and planning for treatment of patient with an advanced cancer. Palliative surgery was unable to be performed. Complex case requiring significant planning and co‐ordination. Inadequate number of operating lists available over summer break. Surgical services to review summer break planning to ensure e timely delivery of time‐critical procedures.

  3. Delay in diagnosis of oral cancer due to lost referral. Referral sent to incorrect email address. Dentist not aware of correct referral process. Establish “e-referrals” as the sole pathway. Communication with all potential referrers. Automatic replies from generic email accounts with instructions on correct pathway. New staff orientation on dealing with patient-related emails received in error.

Treatment Injuries

The Accident Compensation Act 2000, defines a treatment injury.

A treatment injury is a personal injury suffered by a person seeking or receiving treatment from a registered health professional and caused by treatment and not a necessary part or ordinary consequence of the treatment (section 32 of the AC Act).

Before July 2005 medical misadventure legislation covered treatment injuries. Claims lodged before this date continue to be managed under the previous legislation.

If a patient is injured as a result of treatment, they may be able to make a claim and get help through ACC. However, ACC do not cover all treatment outcomes that don’t turn out as expected. 

The injury must occur as a result of treatment from a registered health practitioner:  

chiropractors  clinical dental technicians  dental technicians  dentists  medical laboratory technologists  medical practitioners – doctors, surgeons, anaesthetists, etc  medical radiation technologists  midwives  nurse practitioners  nurses  occupational therapists  optometrists  pharmacists  physiotherapists  podiatrists.

To make a claim the health practitioner should apply to ACC for you. ACC states, the best person to complete the forms is the registered health professional involved in the treatment that caused the injury.

  1. A patient may qualify for cover if they’re injured as a result of treatment by a registered health professional and the treatment, not the patient’s health condition or some other factor, is the cause of the injury.

  2. The treatment from which the injury may stem includes the treatment itself, either given or directed by the health professional, or a lack of treatment that should have been provided.

  3. Under special conditions ACC will consider a claim from someone who was part of an approved clinical trial and suffered complications.

  4. ACC are unable to accept claims resulting from trials that are mainly for the benefit of the maker or distributor of the item being tested.

Some additional information

A patient perspective on adverse events. https://youtu.be/BRHPedoj3Fk

http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11734063

 

http://www.stuff.co.nz/national/health/92065501/acc-admits-treatment-of-christchurch-claimant-despicable

What are the underlying values that apply to adverse events or treatment injuries? The most important value is "caring". When we are in treatment we can expect that everyone involved with actively care for us. Another value is "honesty". When things go wrong, there is an expectation that everyone involved is honest about what happened, and what can change so that this does not occur in the future. The third value relevant here is "pursuit of excellence". That is we all aim to achieve the best possible service, and commit to continuous improvement of services and care. 

Who can help us to attain our entitlements.?

How can you learn more?

Authored by Diana Ayling