Download View Appendix 2 - BMJ Quality and Safety

APPENDIX 2 - Definitions
Adverse Event
An adverse event is an adverse outcome caused by medical care rather than progression of
disease or bad luck.
Preventable Adverse Event
A preventable adverse event is an adverse event caused by error or remediable health system
flaw.
Non-Preventable Adverse Event
An adverse event that is not due to an error or remediable health system flaw.
Potential Adverse Event
A potential adverse event is an error in judgment or in performance that had the potential to
cause patient harm but did not. Potential adverse events are often referred to ‘near misses’.
Adverse Event Triggers
Pre-specified clinical indicators suggesting the patient had or is experiencing an adverse
outcome. The trigger does not necessarily imply the patient experienced an adverse event. The
identification of the event, triggers an investigation into the cause.
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Adverse Event Sub-Types
a) Hospital acquired infections (HAI’s) involve infections occurring as a result of being
admitted to hospital, such as C. difficile associated diarrhea, ventilator associated pneumonia,
and central line associated blood stream infections.
b) Adverse drug events are those caused by medication use. These include events such as
anticoagulant-related bleeding, diuretic-induced renal dysfunction, narcotic-induced
delirium, and hypoglycemic crises as a result of diabetic medications.
c) Surgical adverse events occur as a result of operations. They include events such as
postoperative myocardial infarction, pneumonia, and bleeding.
d) System errors occur when there is inadequate task specification or inadequate resources to
complete goals, where resources can include human personnel or technologies, such as IV
pumps. When the system is poorly designed, errors will ensue and adverse events will arise.
e) Diagnostic errors occur when obvious signs, symptoms, or lab results are not acted upon
leading to an incorrect or delayed diagnosis.
f) Management errors occur when the correct diagnosis is made but is followed by incorrect
treatment decisions. These decisions could include failure to treat, the selection of
inappropriate therapies, or the failure to appropriately monitor a patient’s status.
g) Obstetrical injuries occur in patients injured during labour and delivery. Injuries can occur
to both mother and child.
h) Procedural based injuries are due to harmful effects of non-surgical procedures, such as
endoscopy or thoracentesis.
i) Anesthesia related injuries are due to the delivery of anaesthetic agents.
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Adverse Event Severity Scale
Adverse events may have varying importance to patients. It is important to measure severity as
this will determine the urgency of responding to the adverse events. Using this scale, the most
severe class is selected (the groupings are mutually exclusive).
a) Nil – in this case the event is not truly an adverse event but rather a potential adverse event.
b) Physiological abnormalities - in this case the event caused changes in laboratory parameters
and/or physical signs such as a decrease in blood pressure without causing patient symptoms.
c) Symptoms – in this case the event caused the patient discomfort but did not impair the
patients capacity to perform Activities of Daily Living (ADLs) or IADLs.
d) Transient Disability – in this case the symptoms caused by the event transiently impair the
ability to perform ADLs or IADLs
e) Permanent Disability – in this case the symptoms caused by the event permanently impair
the ability to perform ADLs or IADLs
f) Death – in this case the patient dies.
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