Who Says It's An Adverse Event?

In determining whether or not an adverse event has occurred in the healthcare setting I believe that both the patient’s perspective and the physician’s perspective are very important. It’s difficult, if not impossible to choose only one perspective in evaluating these events.

If I take the definition of The Healthcare Book, the credo for patient safety is “freedom from accidental injury.” I like this definition because it’s pretty straightforward. If the patient is injured accidentally, regardless of the good intentions of the doctors and the risk involved with the procedure—unintentional injury to the patient in any form is an adverse event. Even if the procedure was performed correctly and everything possible was done in good faith to preserve the health of the patient, if an injury occurred or the patient was harmed, I believe that qualifies as an adverse event. I think that it’s important to acknowledge the harm in patients even when procedures are correctly performed and injury is perhaps unpreventable. To not acknowledge the injury to the patient is to accept the issues surrounding the treatment as status quo and there is little incentive to improve healthcare quality.

In determining whether or not an adverse event has actually occurred, it is important to consider the patient and the practitioner’s perspective. Some patients may perceive that they have been the victim of an adverse event when one hasn’t actually happened. If we go back to the definition in The Healthcare Quality Book, I think it’s safe to say that if the patient was not accidentally injured in some way, it’s not an adverse event. A patient might have an emotional scare (i.e. being read the wrong lab results), but if the individual is not actually physically harmed the event should not be reported as adverse. Still, healthcare organizations can learn a lot from slip ups like reading the patient the wrong lab results. Patient complaints of issues in a healthcare facility shouldn’t be ignored, but they also shouldn’t be the final word.

Doctor perspective also should not be the only determining factor on whether or not an adverse event has occurred. Doctors and medical staff typically do not report events at the rate that they occur. Quite the contrary, the number of events reported is far lower than the actual events that happen. This is mostly because health care organizations have not created a “safe” culture for providers to report these issues without fear of disciplinary action. Therefore, physicians and healthcare staff may be more likely to keep adverse events quite to protect themselves.

In order to truly determine if a patient did not receive appropriate care or was accidentally injured, there will likely need to be an investigation by the organization and in some cases state or federal authorities. In any event, the word of the patient and health care provider should be weighed carefully, but the verdict would need to be delivered after a pretty through evaluation of what actually happened. This protects both the patient and the provider.

I Know It When I See It

One of the most interesting aspects of working for a healthcare organization and learning in the HSA program is the ability to gauge whether or not my company actual subscribes to the principals discussed in my classes. It’s actually quite funny that many of the philosophies regarding healthcare quality and strategy are simply ignored by my organization. I would give them the benefit of the doubt and say they don’t know any better, but they’re one of the largest pharmaceutical companies in the world—yet even they have neglected some of the core principles of what not to do when you’re trying to create a high quality organization.

I like Guaspari’s little short story called, I Know It When I See It. It was funny that the “product” of choice was actually punctuation, but I got the gist of the story. What I’ve observed in my company and other large pharmaceutical organizations is exemplified in The Boss’s initial reaction to the success of Process Inc.: “Try harder. Do better.” As ridiculous as it is to read in the story, I’ve actually encountered that attitude first hand from management within my company and I’ve heard similar stories from other reps. The reality is that pharma is a dying industry and most companies were not prepared for the rapid decline of profits (due to patent expiration and generic competition). Rather than take a look at the flaws within the system as a whole, it must be easier to simply tell employees to try harder and do better. Just like Guaspari’s short story, that “direction” from management leads to decreased morality and productivity and exacerbates already existing problems within the company.

After The Boss realizes that “Try harder, do better” adds no value to the organization, he comes up with a plan to implement more inspection within the organization. Ironically enough, my company did the same thing. They’re idea was to mandate more activity—indirectly, this is a way of inspecting the quality of the sales rep’s work ethic and therefore profitability of the organization. How many calls per day were made, how many dinner programs and lunches were set up with doctors. These ridiculous mandates not only ticked off our physicians at times, but they were a waste of energy because people couldn’t focus on what would actually make a difference in the business. The job of a pharma rep represents a non-traditional view of healthcare quality, however it can still be judged as an aspect of quality in relation to the organization. Doctors measure quality not just by the characteristics of the products that reps sell, but the overall interaction with them as well as the pharmaceutical organization.

Eventually, The Boss at Punctuation, Inc. figured out that the problem with his company was within the system. It’s smarter to take an approach of prevention rather than putting out fires. He was eventually able to return his organization to a profitable powerhouse. I do believe that the pharmaceutical industry is attempting to restructure itself due to the fact that it’s a very broken system and profits (at least for my company) have not been reaching projections. They’ll probably eventually get it right, but they’ve wasted a lot of time and money in the process. It just proves the point that quality issues are not necessarily attributable to one source—they typically result from problems within the entire system.