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.