Pathy's Principles and Practice of Geriatric Medicine. Группа авторов
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The primary purpose of reporting systems is to communicate information about patient safety issues so that learning and improvement of systems and practice can occur. A secondary benefit of these systems is that we can use them to assess the scale of harm and identify trends.
There are inherent problems with all reporting systems in healthcare: most studies have found that reporting systems detect only 7–15% of adverse events26 compared with other methods of detection such as case record review. Some of the common barriers to reporting include fear of embarrassment or punishment by oneself or others, fear of litigation, lack of feedback, and a belief that nothing will be done in response to reporting.
Understanding why things go wrong
The investigation and analysis of cases in which clinical incidents have occurred can be used to illustrate the process of clinical decision‐making, the weighing of treatment options and sometimes – particularly when errors are discussed – the personal impact of incidents and mishaps, and critically also includes reflection on the broader healthcare system. Several methods of investigation and analysis are used in healthcare, either retrospectively (for example, root cause analysis or systems analysis of events) or prospectively (for example, failure modes and effects analysis [FMEA]).
Caring for patients after an adverse event
Patients and relatives may suffer in two distinct ways from a medical‐induced injury: (1) from the injury itself and (2) from the way the incident is handled afterward. Many people harmed by their treatment suffer further trauma through the incident being insensitively and incompetently handled. Conversely, when staff come forward, acknowledge the damage, and take positive action, the support offered can ameliorate the impact in both the short and long terms. Injured patients and their families need open disclosure: an explanation, an apology, or to know that changes have been made to prevent future incidents, and they often also need practical and financial help.27
Supporting staff
Making an error, particularly if a patient is harmed because of it, may have profound emotional or psychological consequences for the staff involved. This, in turn, can make future errors more likely and affect teamwork. Factors that may make this more likely include the severity of the error and the reactions of those involved, attitudes toward error, beliefs about control and the power of medicine, and the impact of litigation. Strategies to minimize the effects of adverse events on staff include wider acknowledgement of the potential for error, having an agreed policy on openness with injured patients, encouraging support from colleagues, education and training, and, if necessary, formal support and access to confidential counselling.
Patient safety and older people
The incidence of adverse events in older people in the hospital
Re‐analysis of international adverse event studies
There is considerable evidence that older people suffer a higher incidence of adverse events than their younger counterparts in the hospital. The landmark, international, adverse event studies described in Table 11.1 investigated the incidence and types of adverse events in hospital inpatients of all ages. This was achieved by a two‐stage retrospective case record review in the majority of cases. Table 11.1 also shows that if the results of these large studies are re‐analysed to consider specifically the effects of age on patterns and frequencies of adverse events, they all show that age is a risk factor for adverse events. However, when this relationship is examined more closely, it emerges that comorbidity, rather than age alone, appears to be responsible for this association. In addition to experiencing more adverse events, older people also suffer more serious consequences of adverse events in the majority of studies in terms of morbidity and mortality, increased dependence, increased hospital stay, and a greater chance of institutionalization;28 again, this seems to be related to their physical vulnerability in terms of frailty and diminished physiological reserve. A recent meta‐analysis confirmed that the incidences of adverse events in the elderly varied in different studies, increasing to 60% if geriatric syndromes like falls and delirium were included.29 Besides age, important causative factors were found to be comorbidity, clinical complexity, severity of illness, functional status, and poor quality of care. As might be expected, data from these studies show that older people in the hospital tend to experience different types of adverse events than their younger counterparts, such as falls, hospital‐acquired infections, and drug errors, rather than complications related to invasive procedures. In general, it seems that it is controversial as to whether adverse events are more preventable in elderly than in younger patients.
Data from reporting systems
Another way of estimating the incidence of hospital‐related harm in older people is to analyse data from local and national reporting systems. The incidents most commonly reported to the NRLS in acute hospitals are patient‐related accidents, which in older people are most likely to be falls. These are followed closely by problems related to medication. Such data sources are very useful in terms of allowing us to prioritize areas for intervention. However, it is important to bear in mind that many problems go unreported, particularly those that may not be as obvious as falls or drug errors, so the scale and nature of adverse events may not be truly reflected in this way.
Types of adverse events experienced by older people in the hospital
The geriatric syndromes
During a hospital stay, older people are of course vulnerable to the same adverse events as their younger counterparts, such as hospital‐acquired infections, adverse drug events, deep vein thrombosis, and procedure‐related complications. As described above, there is evidence that the incidence of these types of adverse events is greater in older patients and their consequences are more severe. However, the process and effects of hospitalization in older people, particularly those who are frail and have multiple comorbidities, are different from those in younger people; it therefore follows that any analysis of patient safety and adverse events in this vulnerable population should be undertaken in this context. Figure 11.2 illustrates this in a proposed scheme for the effects of hospitalization in frail older people.
Older people may be admitted to the hospital because of an acute illness, acute exacerbation of a chronic disease process, side effects of treatment for these conditions, or the development of a new geriatric syndrome. These are similar to the geriatric giants first coined by Isaacs in 1965 (immobility and instability, incontinence, and impaired intellect) and are now understood to include delirium, falls, incontinence, pressure sores, depression, undernutrition, constipation, and functional decline. Older patients very commonly have one or more of these conditions at the time they are admitted to the hospital, but there is a strong argument that if any of these truly occur de novo during the inpatient stay and are not related solely to the progression of disease, each should be considered an adverse event because of their association with increased mortality and morbidity and the strong evidence that they are largely preventable.30 The geriatric syndromes rarely occur in isolation – during the complex, lengthy hospital admissions often experienced by older people, they are often interlinked and may contribute to downward spirals in progress and outcome. They can each contribute to or be an outcome of each other; this is illustrated in Figure 11.3, which shows three common clinical scenarios where delirium, incontinence, and falls occur