Professor Chris Baggoley, Chief Executive of the Australian Commission on Safety and Quality in Health Care, sent this email in response to my recent post about the complexity of factors which contribute to errors in the media and health care industries:
While acknowledging that the consequences of actual harm arising from an opinion piece in a newspaper compared to the harm that can occur in a healthcare setting are vastly different, I admire your attempt to draw a parallel between the two situations and appreciate the opportunity to povide advice to the media!
Perhaps the media can learn a lot from the health system if it does choose to analyse its own adverse events. Health offers adverse reporting systems, root cause analysis, open disclosure, handover protocols and systems to respond to the situation of the acutely deteriorating patient. The health system has long acknowledged that “to err is human” and acknowledged that it must work to prevent harm arising fom error, and, where error does occur, to be open about it and to learn from the consequences.
Health has a well established system of reporting of adverse events; in South Australia, for example, health care workers can phone a hot line 24 hours a day, seven days a week and provide information on any actual or potential adverse event, confidentially if they wish. They do not need to complete any paper work, so user friendly is the system.
The Australian Council for Safety and Quality in Health Care brought the process of Root Cause Analysis to the categorisation and analysis of adverse events. Eight of these events, the “Sentinel Events”, are provided by each jurisdiction and are published annually, to the delight of the newspaper sub editors whose most frequent contribution to serious analysis of these complex events is to headline them as simple ‘blunders” and “bungles”.
In response to your own scenario, the potential for such events unfolding is why we have national projects on clinical handover, so that accurate information about patients can be passed on between settings of care and shifts of care.
It is why the Commission is developing national initiatives to recognise patients who are acutely deteriorating while in hospital care and to rescue them when they are deteriorating. It is why Health Ministers have declared that all health care organisations will work to implement the Open Disclosure standard, developed by our predecessor, the Council.
I’m sure there would be any number of health care personnel in Australia happy to help the media sort out its processes of adverse event analysis and reporting at any time!