Elsevier

The Lancet

Volume 363, Issue 9413, 20 March 2004, Pages 970-977
The Lancet

Series
Challenges in the care of the acutely ill

https://doi.org/10.1016/S0140-6736(04)15793-0Get rights and content

Summary

Health care providers, hospital administrators, and politicians face competing challenges to reduce clinical errors, control expenditure, increase access and throughput, and improve quality of care. The safe management of the acutely ill inpatient presents particular difficulties. In the first of five Lancet articles on this topic we discuss patients' safety in the acute hospital. We also present a framework in which responsibility for improvement and better integration of care can be considered at the level of patient, local environment, hospital, and health care system; and the other four papers in the series will examine in greater detail methods for measuring, monitoring, and improving inpatient safety.

Section snippets

Causation

The term medical error has served as a convenient half-truth by which adverse clinical events arising from a presumed chain of causation are attributed to the last link of that chain, usually a doctor or nurse. Health-care institutions have failed to scrutinise the primary elements in a causation pathway11 or search for root causes,12 even though other industries have been implementing error analysis for decades. Error-reduction efforts in health care have focused on the doctor-patient

Comparisons with industry

The safety and error-prevention record for health care services is often compared unfavourably with that of aviation, banking, chemicals, manufacturing, and military services in peacetime, the best of which have highly developed strategies to protect workers and clients. These strategies include a safety culture that emphasises the importance of safe practices, commitment of management to safety, and non-punitive and simplified reporting of errors with feedback of error analyses. Aviation has

Emergency departments

Safe emergency care needs prompt access to initial treatment for life-threatening emergencies, and hospitals cannot provide that if their emergency departments are overloaded by medical problems that could have been managed by a family practitioner or a pharmacist. Patients cannot obtain prompt treatment without either adequate local facilities or an efficient ambulance service. In large hospitals, parallel provision of primary and secondary care within the emergency department improves

Early warning systems

Traditional monitoring in the acute hospital often identifies adverse events only after they occur. Reactive systems, based on instructions to call a doctor if there are major changes in vital signs, should be replaced by proactive monitoring to identify early changes and empower ward staff to call for help and initiate further investigation to prevent or limit the magnitude of adverse events.92, 93, 101

Adverse event and error monitoring

Adverse event reporting is essential for improving patient safety but current methods are

Search strategy

We focused our review on patients' safety and the management of the acutely ill hospital patient. To retrieve information about the health care environment, we also searched for publications about health care organisation and emergency services. We used MEDLINE, EMBASE, and Google, to access government publications and “grey” literature, using singly and in paired combination the terms safety, medical error, postoperative complications, emergency medical services, critical care, and intensive

References (106)

  • VincentC et al.

    Adverse events in British hospitals: preliminary retrospective record review

    BMJ

    (2001)
  • National Audit Office 2000
  • Department of Health

    An organisation with a memory

  • ShawC et al.

    Reporting of adverse clinical incidents: international views and experience

    (2001)
  • BakerGR et al.

    the Patient safety and healthcare error in the Canadian healthcare system: a systematic review and analysis of leading practices in Canada with reference to key initiatives elsewhere—a report to Health Canada

  • BlendonRJ et al.

    Views of practicing physicians and the public on medical errors

    N Engl J Med

    (2002)
  • ReasonJ

    Latent errors and system disasters

  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

    Conducting root cause analysis in response to a sentinel event

    (1996)
  • LeapeLL

    Error in medicine

    JAMA

    (1994)
  • HeinrichHW

    Industrial accident prevention: a scientific approach

    (1941)
  • CohnJN et al.

    New guidelines for potassium replacement in clinical practice: a contemporary review by the national council on potassium in clinical practice

    Arch Intern Med

    (2000)
  • ShojaniaKS et al.

    The autopsy as an outcome and performance measure. Rockville, Agency for Healthcare Research and Quality; 2002

  • HoferTP et al.

    What is an error?

    (2000)
  • BrennanTA

    The Institute of Medicine report on medical errors: could it do harm?

    N Engl J Med

    (2000)
  • McDonaldCJ et al.

    Deaths due to medical errors are exaggerated in Institute of Medicine report

    JAMA

    (2000)
  • HaywardRA et al.

    Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer

    JAMA

    (2001)
  • PerrowC

    Normal accidents: living with high risk technologies

    (1999)
  • LeeTH

    A broader concept of medical errors

    N Engl J Med

    (2002)
  • McNuttRA et al.

    Patient safety efforts should focus on medical errors

    JAMA

    (2002)
  • HoferTP et al.

    Discussion between reviewers does not improve reliability of peer review of hospital quality

    Med Care

    (2000)
  • CamachoLA et al.

    Assessment of the validity and reliability of three systems of medical record screening for quality of care assessment

    Med Care

    (1998)
  • BusseDK et al.

    Classification and analysis of incidents in complex medical environments

    Top Health Inf Manage

    (2000)
  • ShojaniaKG et al.

    Assessing hospital quality: a review for clinicians

    Eff Clin Pract

    (2001)
  • LaydePM et al.

    Patient safety efforts should focus on medical injuries

    JAMA

    (2002)
  • HandlerJA et al.

    Defining, identifying, and measuring error in emergency medicine

    Acad Emerg Med

    (2000)
  • SextonBJ et al.

    Error, stress and teamwork in medicine and aviation: cross sectional surveys

    BMJ

    (2000)
  • BeltonKJ et al.

    Attitudinal survey of adverse drug reaction reporting by medical practitioners in the United Kingdom

    Br J Clin Pharmacol

    (1995)
  • ElandIA et al.

    Attitudinal surveys of voluntary reporting of adverse drug reactions

    J Clin Pharmacol

    (1999)
  • Pizzi L, Goldfarb NI, Nash DB. Crew Resource Management and its Applications in Medicine. In: Shojania KG, Duncan BW,...
  • PoolR

    Beyond engineering: how society shapes technology

    (1997)
  • ReasonJ

    Human error: models and management

    BMJ

    (2000)
  • WeickKE

    Organizational culture as a source of high reliability

    Calif Manage Rev

    (1987)
  • ChassinMR et al.

    The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality

    JAMA

    (1998)
  • ChassinMR

    Is health care ready for six sigma quality?

    Milbank Q

    (1998)
  • LagasseRS

    Anesthesia safety: model or myth? a review of the published literature and analysis of current original data

    Anesthesiology

    (2002)
  • AdamsJ

    Risk

    (1995)

  • House of Lords. Debate on armed forces pension scheme

  • ForsterAJ et al.

    The incidence and severity of adverse events affecting patients after discharge from the hospital

    Ann Intern Med

    (2003)

    • Cited by (0)

    View full text
    Copyright © 2004 Elsevier Ltd. All rights reserved.