Wednesday, October 26, 2011

Adverse Events and Safety of Health Services

There has been considerable coverage of the documents released regarding adverse events at the Canberra Hospital.

There is no doubt that these incidents are a cause for concern and it is life changing for those people affected. 

As a community we need to be alert to the risks inherent in health care but not alarmed.  Overall we have a safe public health system in Canberra but it is not as safe as it could be.

There are robust clinical review processes in place in the ACT Health Directorate and  HCCA has consumer representatives involved in consideration of these errors at a number of levels, clinical review committees, clinical audit committee and the overarching safety and quality committee.

Clinical review is a process which enables us to identify and understand the underlying causes of adverse or near miss clinical events, for the purpose of improving the quality and safety of health care.  The documents that have been released relate to that process.

It is good that there are review processes in place – but what we do have concerns around the successful implementation of the findings of the reviews and how the changes are monitored.  Mistakes continue to be made such as surgery on the wrong side of the body, medication errors. This indicates that the checking procedures are still not adequate.

These committees are underpinned by a quality improvement framework.  A safe health system needs to have a strong reporting culture.  This is not aimed at naming, blaming and shaming but rather identifying and reporting adverse events and near misses so that they can be analysed and issues identified so that improvements can be made and sustained.

If we didn’t have this system of reporting to discover when things go wrong then we wouldn’t be able to make the system safer.

Quality and safety of health care is everybody’s business.  Everyone has a role to play in improving the quality and safety of our services and that includes consumers.  Consumers need to be constantly vigilant and be active participants in our own health care and that of our family.

The 10 tips for safer health care is a useful guide.  
There is an American fact sheet that also is useful to Help Prevent Medical Errors 

By being active and informed consumers we can reduce the risk of harm in the health system


Darlene Cox
Executive Director

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