The human element of adverse events

In this issue of the Journal, review and content analysis of textual summaries of the AEs by Wilson et al, the QAHCS team, have now yielded a deeper understanding of these events.³ The major categories of human error, accounting for over 70% of AEs, were:

• Failures in technical performance;

• Failure to decide and/or act on available information;

• Failure to investigate or consult; and

• A lack of care or failure to attend.

Should we therefore accept that a certain level of error is inevitable in healthcare? We certainly should not accept such high levels of iatrogenic injury, much of which is preventable. In one sense, though, it is necessary to accept error. Before there can be any serious hope of reducing AEs there must first be a recognition of the frequency of error and of imperfect decision-making in healthcare, as is the case in other human activities.⁶ The next step, as the QAHCS team argues, is to look beyond the immediate failures to their deeper causes.³

Analyses of accidents in medicine and elsewhere have led to a much broader understanding of the causes of AEs, with less focus on individuals and more on pre-existing organisational factors. The conditions which give rise to failures in the process of care can be considered in a broad framework of individual, task, team, work environment and organisational factors.⁷ A failure to consult, for instance, may be due to overconfidence in a junior member of staff, inexperience, inadequate knowledge, delay in obtaining test results, or the unavailability of senior members of staff. Each of these problems may be specific to that occasion or may reflect more general problems: the attitudes of individual members of staff, the training policies of the hospital, poor supervisory practices, inadequate and haphazard systems of communication or interpersonal problems within a team.

The National Taskforce on Quality in Australian Health Care produced a comprehensive, multifaceted plan of action to reduce healthcare injuries and deaths.⁸ The Taskforce was surely correct to see both the problem and the solution as multidimensional, as the systems approach implies. Safety programs in industries, involving sociotechnical systems with many similarities to medicine, target the tasks, teams and conditions of work, as well as ensuring that staff are highly skilled.⁴ Safety needs to be addressed both at the level of the particular clinical process and at the interpersonal and organisational levels. Where tasks can be clearly specified, then greater standardisation, clear guidelines and less reliance on the vagaries of human memory and vigilance are essential. Team and communication failures have been strongly implicated in many accident analyses and remedial measures can be straightforward. Systems have also been developed in industry to monitor the conditions of work, as well as the associated organisational factors and decisions that give rise to these conditions.

The Taskforce recommendations have been widely supported⁹ and a number of working groups have been established by Australian health departments. In 1997, a National Expert Advisory Group on Safety and Quality in Australian Health Care was established, and their recommendations will be considered by the Health Ministers later this year. In the 1998 Australian Health Care Agreements, $658 million was allocated for quality improvements within the public health system over five years, and a further $253 million for, among other objectives, improving the integration of public hospital and community services.

Welcome though these initiatives are, the pace of change nevertheless seems slow given the stark message of the original QAHCS study four years ago. The findings from QAHCS suggested that each year 50 000 Australians suffer permanent disability and 18 000 die at least in part as a result of their healthcare. Further evidence emerged in 1997 with the publication of AE rates in Victorian hospitals.¹⁰ Since then, thousands more Australians have presumably been injured or died through deficiencies in the healthcare system. Furthermore, the QAHCS found that AEs lost Australia over three million bed-days per annum. In its interim report, the National Expert Advisory Group pointed out that the extrapolated potential saving from preventable AEs in 1995-96 would be $4.17 billion.¹¹ AEs also lead to increased disability benefits and time lost off work, which all impact on the Australian economy.

Achieving change on the required scale will require a specific commitment from all healthcare providers, administrators and consumers, as well as unequivocal, sustained government support. It is hoped that 1999 will see the necessary consensus for urgent action from all the parties involved and the implementation of specific, carefully evaluated safety initiatives. It would be tragic if the "lack of care and failure to attend" and "failure to decide and act", revealed as causes of AEs, ultimately also applied to those professional and government bodies responsible for programs of prevention.

Charles A Vincent
Reader in Psychology, Clinical Risk Unit, Department of Psychology
University College London, UK

1. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471.
2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med 1991; 324: 370-376.
3. Wilson RMcL, Harrison BT, Gibberd RW, Hamilton JD. An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust 1999; 170: 411-415.
4. Reason JT. Understanding adverse events: human factors. In: Vincent CA, editor. Clinical risk management. London: BMJ Publications, 1995.
5. Cook RI, Woods DD, Miller C. A tale of two stories: contrasting views of patient safety. Report of the National Patient Safety Foundation. Chicago: American Medical Association, 1998.
6. Leape LL. Error in medicine. JAMA 1994; 272: 851-857.
7. Vincent CA, Taylor-Adams S, Stanhope N. A framework for the analysis of risk and safety in medicine. BMJ 1998; 316: 1154-1157.
8. The Final Report of the Taskforce on Quality in Australian Health Care. Canberra: AGPS, June 1996.
9. Wilson RM, Harrison BT. Are we committed to improving the safety of health care. Med J Aust 1997; 166: 452-453.
10. O'Hara D, Carson NJ. Reporting of adverse events in hospitals in Victoria 1994-1995. Med J Aust 1997; 166: 460-463.
11. National Expert Advisory Group on Safety and Quality in Australian Health Care. Interim report - Commitment to quality enhancement. July 1998. <http://www.health.gov.au/about/cmo/neag.htm>

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