THEMES FROM NSLHD SERIOUS ADVERSE EVENTS
A serious adverse event review (SAER) is required for clinical Harm Score 1 incidents or clinical incidents that the Chief Executive determines may be due to a serious systemic problem. The focus of a SAER investigation is on learning from error and strengthening our systems and processes. It is not about individual staff performance. What are the main findings from SAERs for adults receiving general care in the last 5 years?
Top principal incident types
Top 3 clinical risk factors
Inadequate treatment Missed diagnosis Healthcare associated infection Delayed treatment Uncommon complication Death following a fall
Physical co-morbidities
Deteriorating patient*
Confusion and Delirium
0 25 50 75
*Failure to recognise the deteriorating patient
0
5
10
15
The presence of multiple diseases and medical conditions, chronic or acute, in the one person increases the risk the patient will experience serious preventable harm and is associated with more complex clinical management, poor treatment outcomes, longer hospital stays and increased risk of readmission. Adding to the risk of physical co-morbidities is the fact that as age increases the number of co-morbidities also tends to increase, adding to the complexity of the treatment plan and requiring management by multiple care providers.
Top 5 principal incident type
Strategies to mitigate this risk include:
Involve patients, their families and carers in care planning Prioritise continuity of care between multiple care providers and services Provide tools to improve communication between care providers and documentation Ensure that the patient’s medical history is complete, assess medication safety, including undertaking and documenting medication reconciliation
Top human factors
Human factors were identified in many NSLHD SAERs to have contributed to poor patient outcome. The most frequent human factors were ‘Loss of situational awareness’ and ‘Cognitive bias errors’. These have significant impact on decision making, diagnostics and care planning. Situational awareness is about being aware of all the elements in your immediate environment and how they relate to patient and personal safety. It is the careful observation of what’s around us (perception), understanding its significance (reflection) and predicting how it might influence what we are doing (forecast). Read more on page 6. Cognitive bias is defined as ‘failure to understand, synthesize or act appropriately on available information despite adequate education and knowledge levels’. Examples include following the wrong clinical pathway, incorrect pattern matching and/or false hypothesis.
Loss of situational awareness
Cognitive bias errors
Clinical Governance Standard
Knowledge based errors
0
5
10 15
20
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