Safeguarding Patient Well-Being: The Top 10 Adverse Events Hospitals Must Vigilantly Address
Introduction
In the complex shifting landscape of healthcare, the potential for adverse event occurrence remains ever present with hospital leaders playing a pivotal role in ensuring patient safety and quality care. Recognizing and addressing adverse events is crucial for providing a safe care environment for patients and staff. In this post, we'll explore 10 adverse events that hospitals should be vigilant about, and strategies to mitigate these risks.
The top 10 adverse events for patients
Hospital-Acquired Infections (HAIs)
Robust infection control measures are imperative to prevent the spread of bacteria and viruses within the hospital.
Regular training and adherence to strict hygiene protocols can significantly reduce the incidence of HAIs, yet adherence is often below expectations.
Evaluate staff competency on hygiene protocols to develop confidence in the facility's resilience to potential infections and outbreaks.
Medication Errors
Implement systems like Computerized Physician Order Entry (CPOE) and barcode medication administration to minimize prescribing, dispensing, and administration errors.
Regular training for healthcare staff on medication safety protocols is essential and embedding quality-safety checks for common and high-risk medications in daily processes is key.
From our own experience, including pharmacists on daily team rounds can create a standardized process in which expert insights can be brought forward to the rest of the care team, with up to 43% of patients benefitting from a pharmacy intervention.
Patient Falls
Develop and implement fall prevention protocols to ensure a safe environment for patients.
Regular assessments of patients' mobility and timely interventions can reduce the risk of falls.
One published study found that twice-weekly SIBR rounds on an aged care for the elderly service reduced falls by 30% (p < 0.001).
Surgical Complications
Establish comprehensive protocols to minimize the risks associated with surgical procedures.
Encourage a culture of transparency and continuous improvement to address any issues related to surgical errors.
Keep in mind that around half of surgical adverse events occur outside the operating room, i.e. in the post-operative hospitalization. Utilizing team-based care processes after surgery could significantly reduce the occurrence of adverse events, consequently reducing the average length of stay, and improving surgical capacity.
Pressure ulcers
Implement preventive measures, including regular repositioning of immobile patients and the use of specialized mattresses. Ensure staff have a robust mechanism to identify and mitigate early stage pressure ulcers.
Ongoing education for healthcare staff on pressure ulcer prevention is crucial, with standardized processes in place to review and respond to early detection by the care team. Where possible, the use of a pressure ulcer protocol reviewed and with the critical insights brought forward as part of a quality-safety checklist each day within the team creates a robust and resilient strategy to minimize pressure ulcer occurrence.
Venous Thromboembolism (VTE)
Assess and manage the risk of VTE, especially in patients at higher risk.
Establish a process in which the risk of VTE can be efficiently evaluated by the bedside nurse and shared forward to the rest of the team, along with the appropriate intervention during a daily routine process, e.g. interdisciplinary rounds.
Implement prophylactic anticoagulation strategies and educate healthcare teams on VTE prevention protocols and processes.
Diagnostic Errors
Foster a culture of open communication and continuous improvement to reduce misdiagnoses or delayed diagnoses. Be mindful of the potential for the normalization of deviance of patients by individuals and teams during the course of the patient's hospitalization. The team should be cognizant of the patient's baseline before hospitalization and the expectations of recovery post-discharge.
Regularly review and refine diagnostic processes to enhance accuracy with embedded collaborative cross-checks between the care team members, e.g. during team rounds or discharge reviews.
Handoff Communication Failures
Inadequate communication during transitions of care can lead to information loss and errors. Implementing standardized handoff protocols can improve communication and patient safety.
Readmissions
Prioritize care coordination to prevent unnecessary readmissions and finding the most suitable discharge destination to minimize the potential for readmission.
Engage patients and their families in discharge planning, as early as possible. Aim to set the expectations of recovery needs for patients and families based on their diagnosis once known.
Implement patient education and follow-up strategies to enhance post-discharge care.
Adverse Drug Events (ADEs)
Implement medication reconciliation processes to ensure accurate and up-to-date medication lists for each patient.
Provide comprehensive patient education on medication management, including potential side effects and interactions.
It's no surprise that there are a lot of priorities requiring ongoing attention. When we deliver SIBR training to units we often ask participants for the common known complications of hospitalization. Inevitably we hit the same 6-8 pretty quickly: IV access and central line infections, catheter infections, VTE/DVT, pressure ulcers/wounds, falls, glycemic events and medication events. To proactively mitigate these known common complications, we've embedded them into the SIBR rounds communication protocol, to bring the team's attention to them. Preventing a normalization of deviance and limit the potential for clinical inertia.
Hospital leaders pay attention to adverse events for several critical reasons that directly impact patient safety, quality of care, and the overall effectiveness and reputation of the healthcare institution. Implementing these strategies supports the necessary comprehensive approach to care improvement including policy development, staff education, patient engagement, and the implementation of targeted processes, technology and safety tools. Hospitals should continually assess their patient safety practices, encourage a culture of safety, and engage in quality improvement initiatives to reduce the occurrence of adverse events.
Bonus adverse events to focus on once you've mastered the 10 above
In addition to these common complication of hospitalization, consider these other emerging and somewhat silent contributors to declines in patient outcomes:
Functional deconditioning for patients while hospitalized, with mobility and Activities of Daily Living often seeing significant declines with each day that passes. Optimized referrals to physiotherapy and occupational therapy are key to targeting early discharges and reducing readmissions.
Hospital induced delirium from medication regimens - Hospital-induced delirium can affect individuals of any age but is more common in older adults. It poses challenges for healthcare providers in delivering optimal care and may lead to prolonged hospital stays, increased morbidity, and complications. Preventative measures include careful medication management, maintaining a regular sleep-wake cycle, and minimizing factors that contribute to delirium, emphasizing the importance of a patient-centered approach to promote cognitive well-being during hospitalization.
Aspiration - events are often associated with specific patient populations, such as those with swallowing difficulties, neurological disorders, or compromised respiratory function. Changes in the prevalence of these conditions, as well as variations in hospital protocols and patient management practices, can influence the occurrence of aspiration events.
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