Adverse Events: Consequences of Error

Purpose:

Understanding the effects of an unanticipated adverse or near miss patient event has implications for the well-being of healthcare professionals, the retention of staff, and the sustainability of a healthy practice environment. For the purposes of this study an adverse event is an unanticipated patient injury or complication that is a caused by healthcare management rather than the patient’s underlying disease process. Healthcare management includes actions of individual health care providers, as well as broader systems and care processes, and includes both acts of omission (failure to diagnosis or treat) and acts of commission (incorrect diagnosis or treatment, or poor performance). A near miss occurs when a healthcare management error has occurred but the patient does not experience injury or harm.

Several researchers have concluded that the occurrences of adverse events in complex healthcare environments are inevitable (Waterman et. al, 2007; Baker et al., 2004; Sears, Baker, Barnsley, & Short, 2013). When an adverse event occurs it is readily acknowledged that there are consequences for the patient and that the costs of caring for that patient increase because of the adverse event. The costs associated with healthcare professionals’ reactions to adverse events are unknown; but are thought to be significant (Statistics Canada, 2013; Canadian Institute for Health Information, 2001). These reactions may include compassion fatigue (Austin, et al., 2013) and moral distress (Austin, et al., 2009). Healthcare professionals who have experienced traumatization as a result of being involved in an adverse event may have an increased risk for burnout (Chenevert, et al., 2013; Waterman et al., 2007; Wu & Steckelberg, 2012). Healthcare professionals’ have also reported that they experience illness and disability as a result of having inadequate organizational support; which includes working short staffed, lacking equipment, having a lack of leadership, and a lack of a meaningful and cohesive team affect. These experiences weaken their commitment to the organization and they experience diminished professional empowerment (Lashinger, et al., 2012).

The lack of organizational commitment then has the potential to lead to organizational stagnation and potential collapse (Porter-O’Grady & Malloch, 2011). The cost to the healthcare system related to healthcare professionals’ reactions to adverse events is unknown. However, on average, healthcare professionals lose twice as many days to illness and disability than do those in the general working population (Statistics Canada, 2013). Nurses lose more time to illness and disability than workers do in any other profession (Canadian Institute for Health Information, 2001). Determining the reason(s) for these high rates of lost time is complicated. It has been suggested that one of the potential causes for the increased rate of illness and disability is related to psychological reactions to the stress and demands of the workplace.

Research supports the notion that healthcare professionals are affected by their experiences with adverse events. However, there is disagreement on how they are affected. Researchers have also identified that healthcare professionals should be supported after they are involved in an adverse event, but there is disagreement on the most appropriate means of support.

Methods:

 Using a qualitative descriptive approach individual interviews were used to gather information about the reactions and experiences of healthcare professionals after they are involved in an adverse event. The interviews were recorded and then transcribed. Themes were then identified.

Results:

 Healthcare professionals experience many reactions to their involvement in adverse events. These reactions include a sense of isolation and frustration. Additionally participants reported a lack of confidence, remorse, and self doubt after the incident.  They also described experiencing a number of physical as well. All of the participants had suggestions on how the organization could better support health care professionals in the future.

Conclusion: There are concequences to being involved in an adverse event whether or not you are a patient or the healthcare professional involved. There are opportunities for organizations to better support the staff, faculty and students involved.  These strategies may be one of the means of reducing burnout and moral distress within health professionals.