Unfavorable events may occur in any environment, including a hospital setting. It is not possible to predict all adverse events that may take place after a patient is admitted to a hospital. However, healthcare institutions should have strategies to learn from experience and minimize the occurrence of such events in the future. This text will discuss an adverse event that occurred in the author’s career and a corresponding quality improvement initiative.
Analysis of the Adverse Event
This paper will be based on the discussion of an adverse event that involved a physician at a hospital. The patient was a middle-aged man who was admitted to the hospital due to rectal bleeding. After conducting a sigmoidoscopy, the physician assured the patient that no severe problems were found. However, the patient was readmitted to the hospital almost two years later due to the same problem. It was discovered that the physician had not conducted a thorough examination of the patient’s sigmoid colon. The physician did not make use of other diagnostic procedures. The reason why the patient had continuous rectal bleeding was cancer, but by the time it was discovered, it had become incurable. With proper diagnostic management, it would have been possible to prevent the disease from developing.
In terms of protocol deviations, the physician’s performance of sigmoidoscopy was correct. However, it was an error to dismiss the patient without determining the root cause of rectal bleeding. Therefore, the diagnostic protocol should have indicated the necessity of colonoscopy. The physician either deviated from the protocol if colonoscopy was required or conducting colonoscopy was not necessary according to the protocol. In both cases, it is a management error – there should be reporting mechanisms to ensure that all steps of the diagnostic protocol are followed. The procedure should be comprehensive and rigid to avoid adverse events. Conducting colonoscopy might have helped diagnose cancer in the early stages of its development. According to the latest statistics, missed cancer diagnoses comprise 46% of all diagnostic errors (Aaronson et al., 2019). This number is significant, and a thorough managerial intervention is required to resolve this issue.
Implications for Stakeholders
Short-term impacts on the patient included continuous rectal bleeding and pain. Long-term consequences were more severe – metastases developed that reached the liver, and the patient died within 20 months when the advanced disease was diagnosed. The family referred to solicitors to claim compensation due to substandard care. The case resulted in a damaged reputation of the hospital and the interprofessional team. The management team was contacted by the government to obtain detailed reports of what had happened. Eventually, the hospital had to pay a substantial amount of compensation to the deceased patient’s family.
There are three responsible parties in this case – the physician, the management team, and the hospital registrar. The latter individual is responsible for collecting and inputting patient information into the information system. When a patient arrives with rectal bleeding, information about potential diagnostic requirements should be recorded. This information should then be viewed and managed by the management team. The physician is responsible for delivering quality care and conducting comprehensive diagnostics every time. Not all parties were found responsible in the beginning, however. The physician was involved directly, and therefore, he took the entire responsibility. However, it is significant to analyze what steps and deficiencies in the system led to medical errors. After the event, the hospital management developed a comprehensive diagnostic protocol, which is now controlled by a digital system. The system provides information about what procedures should be accomplished, and doctors are responsible for performing them and inputting the results. In case of deviations, the system reports to the management team, and subsequent steps are considered.
Related Quality Improvement Technologies
It is not possible to account for all errors that might occur. Therefore, it is important to have a process of continuous improvement. While it is imperative to avoid any significant medical errors like the one discussed, small mistakes can be used to identify potential shortcomings of the current system. Evidence suggests that reporting and documenting near misses contribute significantly to quality improvement. Crane et al. (2015) developed a reporting system anyone can use to report near-misses anonymously. The results of the study reinforce the claim that near-misses can be used to implement Quality Improvement (QI) initiatives. By the end of the research, there were 632 near-miss reports, which resulted in the initiation of 32 QI projects (Crane et al., 2015). The role of the management team is crucial in this context – while medical personnel is responsible for reporting near-miss events, it is the responsibility of leaders to launch QI initiatives.
After the death of the patient, a thorough investigation discovered that filing errors and mistakes in electronic health records contributed to substandard care. It was decided to integrate a near-miss reporting system to identify any areas that might need improvement. Proper utilization of this technology largely depends on the willingness of healthcare workers to report. In the beginning, reporting rates were low, and the management decided to conduct a separate series of training sessions dedicated to near-miss reporting. After this training, reporting rates increased, and now it can be concluded that the technology is being used appropriately. Many healthcare institutions have similar systems that monitor adverse events, but they are not effective (Rafter et al., 2015). The researchers suggest that the lack of standardized measurement tools is the reason why current reporting systems are ineffective (Rafter et al., 2015). Therefore, it may be significant to develop an internationally recognized measurement standard.
Motivation for Improvement
For patient safety improvement, two metrics are vital – the number of reported near-misses, and the number of adverse events. Scientific evidence suggests that reported near-misses often lead to a decline in the number of adverse events when proper QI projects are initiated. Therefore, when the number of reported near-misses increases, there should be a substantial decrease in the number of adverse events. The absence of this trend may indicate the fact that no QI activities are being undertaken. It is not possible to draw apparent conclusions from the data obtained from the facility’s dashboard. Different periods depict varying numbers of reported near-misses. There is no specific trend in these variations; in other words, the number of reported near-misses neither increases nor decreases continuously. The same picture can be observed in the number of adverse events over time. There can be two explanations – managers are not initiating QI projects due to negligence, or the system is failing to categorize each of the reports adequately.
The first explanation is potentially the correct one because a similar trend is observed in hospitals. In a study conducted by Harrison et al. (2014), respondents indicated that almost half of the reported near-misses result in nothing but mere empathy from colleagues. Only 20% of cases result in process improvements and systems changes (Harrison et al., 2014). Reporting systems are not bringing tangible benefits in practice. It is vital to establish the exact reasons why leaders are failing to start QI initiatives.
Outline of Quality Improvement Initiative
The facility continues to use a near-miss reporting system to identify potential shortcomings in the system. The diagnostic protocol is supervised by corresponding managers, and they are responsible for encouraging employees to report near misses. These managers are responsible for addressing any identified systems issues by developing QI projects. In case the reports are not automatically categorized by the system, a separate team is designated to analyze the reports manually. Brainstorming sessions occur among managers to research new ways of improving patient safety, but the near-miss reporting system is currently the only mechanism that is working at the facility. Because this system was proposed at a higher management level, there are no significant differences between how varying facilities aim to improve quality. They have a different information system, but the reporting procedures are almost the same.
One example of a QI project at the facility is the hand hygiene improvement program. This initiative was proposed after numerous employees reported that health workers often forget to sanitize their hands after dealing with a patient. Some of the workers indicated that the lack of hygiene products and inconvenient placement of sanitizers as the reason. After reading these reports, the management team surveyed to determine the convenient locations for the placement of sanitation tools. After the necessary equipment was installed, all employees received training on hand hygiene in the form of short seminars. While near-miss reporting is a beneficial mechanism, it is not sufficient to prevent all adverse events. Another potential option is to develop a patient reporting system that would allow patients to give immediate feedback. This approach, along with near-miss reporting, will deliver more comprehensive results.
In summary, a near-miss reporting system has the potential to decrease the number of adverse events in a healthcare setting. Such a system allows an organization to monitor current performance and identify potential risks. Mitigation techniques can then be used to eliminate the identified shortcomings. Near-miss reporting is currently the only option with proven efficacy and real-world cases of implementation. Further research is needed to evaluate other techniques and approaches.
Aaronson, E. L., Quinn, G. R., Wong, C. I., Murray, A. M., Petty, C. R., Einbinder, J., & Schiff, G. D. (2019). Missed diagnosis of cancer in primary care: Insights from malpractice claims data. Journal of Healthcare Risk Management, 39(2), 19-29.
Crane, S., Sloane, P. D., Elder, N., Cohen, L., Laughtenschlaeger, N., Walsh, K., & Zimmerman, S. (2015). Reporting and using near-miss events to improve patient safety in diverse primary care practices: A collaborative approach to learning from our mistakes. The Journal of the American Board of Family Medicine, 28(4), 452-460.
Harrison, R., Lawton, R., & Stewart, K. (2014). Doctors’ experiences of adverse events in secondary care: The professional and personal impact. Clinical Medicine, 14(6), 585-591.
Rafter, N., Hickey, A., Condell, S., Conroy, R., O’Connor, P., Vaughan, D., & Williams, D. (2015). Adverse events in healthcare: Learning from mistakes. QJM: An International Journal of Medicine, 108(4), 273-277.