The GOLDEN RULE

Part of the University of Adelaide campus at North Terrace. (View of Eastern side of the Mitchell Building.) (Photo credit: Wikipedia)

This is a possible case of copyright infringement but I find it hard to believe that it is not considered as fair use and of justifiable value to the public. Due acknowledgement is made to the author and a source reference supplied here.

This extract sums up the need for publishing this here –

“The current high rate of adverse events has recently come to public light with the publishing of large studies in Australia and the United States of America (USA). So dramatic were the results of the USA study that it led to a presidential dedication to implement a program aimed at decreasing medical errors by 50% in the next 5 years from the year 2000 [5] .”

Michael Edmonds
This article was written by Michael Edmonds during his PhD studies in the Health Informatics Unit, Faculty of Health Sciences, University of Adelaide, circa 2005.

Definition
An adverse event is defined as an “injury resulting from a medical intervention, not the underlying condition of the patient” [1] , and is also referred to as iatrogenic injury, which has been defined as “unintended or unintentional harm or suffering arising from any aspect of health care management” [2] . An adverse event is preventable if it is due to “an error in management due to failure to follow accepted practice at an individual or system level”, where accepted practice is “the current level of expected performance for the average medical practitioner or system that manages the condition in question” [3] .

It has long been recognised that adverse events pose a threat to the safety of patients [4] . This became a prominent issue in the Californian litigation crisis of the early 1970s when an upsurge in litigation cases spurred an investigation that showed that 4.6% of all admissions were associated with a “potentially compensible event” [2] . The current high rate of adverse events has recently come to public light with the publishing of large studies in Australia and the United States of America (USA). So dramatic were the results of the USA study that it led to a presidential dedication to implement a program aimed at decreasing medical errors by 50% in the next 5 years from the year 2000 [5] .

Adverse event data has not been studied or published in the past for many reasons. Adverse events in medicine were never reported systematically, like aviation accidents or motor vehicle accidents, and the scope of the problem has never been previously defined. Medical culture also urges the health care professional to strive for error-free practice. Making an error is seen as a failure of character and there is a reluctance to report adverse events for fear of individual blame and litigation [3] . Other reasons that have been suggested include that it is difficult to access confidential patient files, and that most errors arising from sub-standard performance are believed to be self-regulated within the profession. The changing role of the patient in relation to the doctor is also a factor, with the better informed patient now having the social power to ask about error and failure. Progress in medical technology means that policy and management struggle to maintain protocols and safeguards to keep pace with new advances [2] .

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