Beneath the Radar

Clinical error is the third biggest killer in hospitals – more than breast cancer and trauma.

Professor Bill Runciman says of Australian healthcare ‘Without re-design the system will continue with relentless inefficiency to kill 10,000 patients and generate 500,000 adverse events ….’

In this series of posts we explore how frameworks in healthcare may be detrimental to delivering effective safety solutions, and provide avenues to fix the problem.

Throughout the world incident reporting systems do their best to recognise clustering of adverse events, however these events continue to occur unabated.

Many adverse events occur rarely, and thus to observers in the institution may seem to be isolated (outlier) cases. Commonality and common causation only emerge with analysis of aggregated data. Similarly, demonstrating occurrence of serious events in respectable peer institutions helps counteract a typi-cal response of “that could never happen here”, which providers may genuinely feel when asked about a serious adverse event, such as amputation of the wrong leg. (World Health Organisation 2005)

Perhaps those further removed from the location of adverse events don’t possess the emotional obsession required to implement effective solutions. And perhaps those at the location of an event suffer a lightning strike effect ‘it’s not going to happen there again’ – they may be right, that institution may put effective measures in place and lightning won’t strike that institution again – but what about the others?

The chlorhexidine epidural tragedy is an unfortunate example where after a near miss at one institution the adverse event occurred nearby at another. Almost ten years later and sadder still we have yet to implement an obvious response to this by prohibiting Riotane tinted pink.

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