Conference presentation to the NZ Interprofessional Health Conference 5th July 2016

1. Role of Miscommunications
in Adverse Events
Ailsa Haxell, Terry Weblemoe, Alex Bowmar
School of Interprofessional Health Studies
Faculty of Health and Environmental Sciences

2. Adverse events (AE)
Is generally defined as:
1) an unintended injury
2) resulting in disability, and
3) caused by healthcare management rather
than the underlying disease process
(Davis et al, 2003)

3. Adverse event rates
(Kohn, Corrigan & Donaldson, 1999)
Country Author & year AE rate (as%) AE deaths (%)
USA Kohn et al., 1999 2.9-3.7 2.9 - 6.6
Australia Wilson et al., 1995 16.6 51
Canada Baker et al., 2004 7.5 20
England Vincent et al., 10.8-11.7 48
Netherlands Zegers et al., 2009 5.7 12.8
New Zealand Davis et al., 2002 11.2 15

4. Equivalent to
4 Boeing 747 crashes every year (Evans, 2007)
Image cc licence https://upload.wikimedia.org/wikipedia/commons/7/7d/CID_post-impact_1.jpg

5. 3x the death rate
from motor vehicle accidents (Evans, 2007)
Image cc licence http://www.teara.govt.nz/en/road-accidents

6. DALY:
a measure of fatal and non-fatal impacts combined as a measure of health loss
(MOH, 2013)

7. Iatrogenesis
The adverse and unintended outcomes of health
service delivery.
(Illich, 1975)

8. • Incident reporting is largely restricted to in hospital
care, and limited to physical harm
• (See for example Brennan etal, 1991; Wilson et al., 1995; Kohn, Corrigan &
Donaldson, 1999; Thomas et al., 2000; Vincent, Neale & Woloshynowych, 2001;
Davis et al., 2002; Baker et al., 2004; Zegers et al., 2009)
• Provider capture? Records of adverse events are most
commonly the result of incidents as reported by health
professionals (Harrison .et al., 2015).
• Little correlation (0.4%) between adverse events
reported by patients to Health and Disability
Commissioner and those documented by health
professionals. This increases to just 4% when reviewing
those classified as serious and preventable (Bismark et al.,
2006).
Documentation of adverse events
is but the tip of an iceberg

9. Country Author, year Preventable AE % Recommendation
USA Kohn et al.,
1999
27.6 - 76 Non punitive reporting
Standardize & simplify processes
interdisciplinary team training
Improve medication systems
Australia Wilson et al.,
1995
51.2 Improve systems
Inadequate reporting
Averse to blaming individuals
Canada Baker et al.,
2004
36.9 Improve medication safety
Modify work environment
Leadership
Improve reporting
Improve coordination
Improve communication
England Vincent et al., 48 Not discussed
Netherlands Zegers et al.,
2009
39.6 Organisational
Review surgical procedures
New Zealand Davis et al.,
2002
Improve systems
Consultation
Education

10. We thought the data was a little old.
We wanted to know if there had been improvement
Review of the literature:
The more recent literature is questioning the
accuracy of the data reported, the definitions of AE,
the data collecting, the limitations of coding…
and the absence of a consumer voice.

11. An alternative narrative
we “listened” to recipients
of health services
Image: Authors own

12. Method: Stage 1*: We reviewed 100 case studies
on the HDC website (April 2013-April 2014)
Interim Findings:
• In these case studies, healthcare is not
geographically bound by hospitals.
• Definitions of harm are markedly different to those
attended to in previous studies of adverse events.
• Harm extends to mental, spiritual, emotional,
relational, sexual, financial as well as physical harm.
* Stage2 (in process) – reviewing all case studies from 2012 to current using NVivo coding
software, coding for adverse events, range of health professionals involved, site of health
care service provision, as well as for the range of miscommunication contributing to
adverse events.

13. Further findings:
Recipients of healthcare, at least in these case
studies, tend not to talk of system failure, or better
surgical procedures, or medication systems, or
improving the reporting of adverse events….
In ninety-nine out of hundred case studies, it is
miscommunications that are implicated.

14. We are loathe to accept that:
Iatrogenesis is compounded by the inability
of those within the established institutions
of health service delivery to critically
consider the harm that they perpetuate
(Illich, 1975).
And therefore ask:
“What could we, should we, will we, do?”

15. References
Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J., . . . Tambly, R. (2004). The Canadian adverse
events study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association
Journal, 170(11), 1678-16
Bismark, M. M., Brennan, T. A., Paterson, R. J., Davis, P. B., & Studdert, D. M. (2006). Relationship between
complaints and quality of care in New Zealand: a descriptive analysis of complainants and noncomplainants
following adverse events. Quality and Safety in Health Care, 15, 17-22. doi: 10.1136/qshc.2005.015743
Davis, P., Lay-Yee, R., Briant, R., Ali, W., Scott, A., & Schug, S. (2002). Adverse events in New Zealand public
hospitals I: Occurrence and impact. The New Zealand Medical Journal, 115(1167).
Davis, P., Lay-Yee, R., Briant, R., Ali, W., Scott, A., & Schug, S. (2003). Adverse events in New Zealand public
hospitals II: Preventability and clinical context. New Zealand Medical Journal, 10(116).
Evans, S. (2007). Silence kills--challenging unsafe practice. Kai Tiaki: Nursing New Zealand, 13(3), 16-19.
Harrison, R., Walton, M., Manias, E., Harrison, J., Smith-Merry, J., Kelly, P., . . . Robinson, L. (2015). The missing
evidence: a systematic review of patients' experiences of adverse events in health care. International Journal for
Quality in Health Care, 27(6), 424-442. doi: 10.1093/intqhc/mzv075
Illich, I. (1976). Medical nemesis: The expropriation of health. New York: Pantheon Books.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999). To Err Is Human: Building a Safer Health System.
Washington, DC: National Academy Press.
McCaughan, D., & Kaufman, G. (2013). Patient safety: threats and solutions. Nursing Standard, 27(44), 48-55.
Ministry of Health. (2013). Health loss in New Zealand: A report from the New Zealand Burden of Diseases,
Injuries and Risk Factors Study, 2006–2016. Wellington, New Zealand.
Ocloo, J. E. (2010). Harmed patients gaining voice: Challenging dominant perspectives in the construction of
medical harm and patient safety reforms. Social Science & Medicine 71 (2010) 510e516, 71(5), 510-516.
Paterson, R. (2013). Not so random: patient complaints and ‘frequent flier’ doctors. British Medical Journal
Quality and Safety(22), 525–527. doi: 10.1136/bmjqs-2013-001902
Rosenthal, M., Cornett, P., Sutcliffe, K., & Lewton, E. (2005). Beyond the medical record: Other modes of error
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Wilson, R., Runciman, W., Gibberd, R., Harrison, B., Newby, L., & Hamilton, J. D. (1995). The Quality in Australian
Health Care Study. Medical Journal of Australia, 163, 458-471. Zegers, M., Bruijne, M. C. d., Wagner, C.,
Hoonhout, L. H. F., Waaijman, R., Smits, M., . . . Wal, G. v. d. (2009). Adverse events and potentially preventable
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