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Part 5: Adverse Medical Events

Identify Opportunities for Improvement


Adverse Medical Events Assessment

Continuous quality improvement has been and continues to be a central issue within health care. The medical office must perform certain activities in order to accomplish its goals in preventing medical errors and improving patient safety.

Adverse medical events refers to any error, incident, injury or other unintentional harm to a patient as a result of medical treatment. Adverse medical events are the result of system failures, human errors, or a combination of both.

System failures may be a result of:

  • Poor communication
  • Insufficient or absent documentation
  • Inadequate resources
  • Lack of internal controls
  • Insufficient staffing levels
  • Negative workplace culture
  • Poor management decisions

Human errors may be a result of:

  • Lack of proper training
  • Failure to properly diagnose
  • Delay in treatment
  • Failures of attentional behaviors
  • Lack of proper follow-up
  • Poor performance
  • Lack of motivation

To prevent adverse medical events, the medical office is responsible for the continuous assessment, monitoring, implementation and enforcing of processes that promote patient safety standards.

A complete assessment of adverse medical events involves 4 key components.

Identifying Potentially Preventable Events

What type of adverse events can you identify?
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According to the Centers of Medicare and Medicaid Services, there are four major categories of preventable events.
  1. Events Related to Infection Some examples are:
    • Urinary tract infection
    • Respiratory infection
    • Bacterial infection
    • Surgical site infection
  2. Events Related to Medication Some examples are:
    • Allergic reaction
    • Severe headache and dizziness
    • Change in mental status
    • Respiratory complication
  3. Events Related to Surgery/Procedures Some examples are:
    • Excessive bleeding
    • Cardiac complication
    • Foreign body left at surgery site
    • Transmission of infection to patient
  4. Events Related to Patient Care Some examples are:
    • Fractures or other injury due to patient fall
    • Exacerbation of preexisting medical condition
    • Congestive heart failure (CHF)
    • Oxygen deficiency

Other adverse event categories include:

Product, Device or Equipment
Patient Protection
Care Management

Determining Preventability of Adverse Events

What adverse events are preventable?
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As part of the adverse medical events assessment, the medical office must determine which events are preventable. To precisely gauge the extent to which an event is preventable, the events identified as potentially preventable should be grouped into three categories.

  1. Preventable: The event is directly related to system failures or human error and could be avoided with proper assessment and implementation of continuous quality improvement.
  2. Non-Preventable: The event occurs despite proper protocol being followed and policies and procedures in place that meet acceptable quality standards.
  3. Unable to determine: The event is unable to be determined because data did not clearly support the circumstances surrounding the event.

Methods of Assessing Adverse Events

What art the best methods for assessing adverse events?
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All methods of assessing adverse events should be identified for relevancy, validity and reliability. There are several tools to compile, classify and organize data for the purpose of error detection and monitoring within the medical office. Here are different methods for assessing adverse events.

Medical record review
Chart audits
Incident reporting systems
Direct observation
Interviews and polls
Autopsy reports

The best methods are based on a standardized method of collecting data. Depending on the volume of the medical office, it may be necessary to use an electronic system. Manual tracking tends to be less effective than the use of electronic capture or software system which can record, track and monitor patient data in greater numbers.

Countermeasures for Adverse Medical Events

What countermeasures can be taken for adverse medical events?
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The effectiveness of assessing adverse medical events also relies on how well the countermeasure matches the type of event and whether the event is a result of system failure or human error.

During your assessment, consider the countermeasures currently in place as they relate to the identified events.

Are your countermeasures utilized in a way that provides a sufficient method of preventing and detecting adverse medical events?

  • Red flags: Provide an effective reminder system for certain tasks
  • Checklists: Provide assurance that each task is identified and performed
  • Inspections: Provide a backup to help avoid or respond early to errors
  • Continuing education: Provide learning opportunities on an ongoing basis
  • Motivation: Get maximum performance from your employees
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