Skip to main content

Advertisement

Table 1 Error learning and mandatory disclosure

From: Increasing the options for reducing adverse events: Results from a modified Delphi technique

Proposals Effecta [1 = v.high 6 = negative] Mean (std dev) Implementb (months) Impactc (months) Totald (years)
1.1 Providers, including doctors and hospitals, should receive immunity against litigation relating to adverse events that have been reported, and compensation to an injured party or parties should be paid for from a subsidised government or privately run claims-fund where compensation is not contingent upon blame. 2.17 (.79) 42 55 8.38
1.2 Reporting of adverse events should be mandatory. 2.29 (1.45) 9 9 1.5
1.3 Remedial or punitive action against service providers should be independent of compensation paid, and all providers should be affiliated with an accredited body which reviews, collates and provides summary information about adverse events to providers. 2.35 (1.00) 26 26 4.3
1.4 Procedures should be mandated that facilitate and encourage the reporting of incidents by patients. 2.19 (1.11) 9 8 1.4
1.5 There should be mandatory incident reporting not just mandatory disclosure of adverse events, and mandatory review of systems following an unexpected increase in the frequency of incidents, in all public and private hospitals.e 2.18 (1.29) 11 9 1.7
1.6 There should be complete reporting of all patient outcomes, not only incident reporting. 2.41 (1.66) 64 28 7.7
1.7 All hospital deaths should be reviewed by an independent clinical governance department and deaths suspected of being related to an adverse event, plus any action take to prevent such events in the future, should be reported.f 2.31 (1.08) 10 18 2.3
1.8 All implanted devices, such as pace makers, should have a unique identifier. Whenever a clinician or patient reports a problem, or when a device is removed, or a patient dies with a device in place, this should be recorded on an electronic data base. This data base should be continually monitored for patterns that might indicate a problem.g 2.33 (.97) 10 21 2.6
1.9 Hospitals should collect and report data on preventable post-discharge complications after elective surgery. 1.93 (.59) 11 21 2.7
  1. a Respondents were asked to rate the potential effect of the option on a six-point scale: 1 = very high, 2 = high, 3 = low, 4 = very low, 5 = none, 6 = negative. Lower scores indicate a higher potential effect.
  2. b How quickly it could be implemented. First the mean was calculated using the following scale: 1 = immediate, 2 = one month, 3 = six months, 4 = one year, 5 = five years, 6 = ten years (or more). Then the result was converted into months. For example, a mean score of 4.63 = 1 yr + 63% of 48 months (5 yrs – 1 yr) = 42 months (1 yr + 30.24 months).
  3. c Time before the option would be likely to have a major effect: 1 = immediate, 2 = one month, 3 = six months, 4 = one year, 5 = five years, 6 = ten years (or more). See above for method of converting into months.
  4. d Implementation time plus impact time.
  5. e In Victoria mechanisms are currently in place to ensure that Root Cause Analysis (RCA) is conducted following an increase in the frequency of incidents in public hospitals.
  6. f The Quality and Safety Branch of the Victorian Department of Human Services and the State Coroner's Office already carry out these functions in Victoria with full investigation and recommendations are promulgated.
  7. g To some extent this already occurs – e.g. in the case of heart valves [31] and joint replacements [32].