Patient safety events at KEMH
Hospital reveals harm figures
The island’s general hospital logged 430 incidents that resulted in harm to patients over less than five years, Bermuda Hospitals Board statistics have revealed.
Of those, 28 fell into the three most serious categories of harm — 14 patients died unexpectedly, 5 needed life-saving treatment and 9 suffered permanent harm as a result.
The figures were included in statistics released by BHB that showed there were 4,090 incidents reported by staff at the King Edward VII Memorial Hospital between March 28, 2011 and December 31, 2015.
The number of reported incidents that involved patients is far higher than earlier reported by the hospitals board.
The most common events involved falls or slips and medication errors.
BHB released data in December 2015, in response to a public access to information request from The Royal Gazette, which logged only 13 events between 2011 and 2015.
Michael Richmond, BHB’s chief of staff, said yesterday that the number of reported adverse events at the hospital was comparable with similar institutions overseas, based on his experience, although there was no established international benchmark.
He added that any adverse events had to be viewed as potential for improvement and were taken seriously.
Dr Richmond said it was unwise to over-interpret the data, because it only included incidents that staff reported.
He explained that some incidents would not be reported and that many credible articles suggested only 15 percent of events were picked up by hospital reporting systems.
He said: “Reporting systems are notoriously weak and inconsistent in identifying all harm events.”
A total of 534 incidents were reported at KEMH amid about 6,000 hospital admissions, 30,000 emergency department attendances and 6,300 outpatient procedures last year.
There were 900 reported events in 2012, against a backdrop of similar hospital activity. The World Health Organisation says European data consistently shows that medical errors and healthcare-related adverse events occur in 8 to 12 per cent of hospitalisations.
Dr Richmond said he was unable to provide the numbers to enable a comparable rate to be calculated for KEMH but it may be possible in the future.
He said he was less concerned about how the figures compared internationally and more worried that the number of reported events at KEMH was falling because of a failure to report.
He said: “I’m very worried that we have got a reduced level of reports.”
He added that his aim was to create a culture at the hospital where reporting was encouraged because that would lead to improvements in patient safety.
Dr Richmond said: “We are putting a system in place where the frontline staff are the eyes and ears of the organisation.”
He added that specific projects had been launched to target the most common kinds of accidents and errors.
The chief of staff said the figures released to The Royal Gazette in 2015 included only those incidents in the “sentinel events” category — those that could have or did lead to unnecessary death or major harm and could have been prevented.
He added: “There was no effort to mislead. That was the way it [the Pati request] was interpreted by whoever. It would appear that the numbers were low.”
He said the 13 sentinel events were a subset of the 4,090 reported adverse events.
Dr Richmond added that the board did not have data showing how many of the remaining 4,077 events were preventable or had involved hospital error —although each logged incident was reviewed to determine what happened and action was taken if needed.
Dr Richmond, who joined BHB last July, said “many” of the incidents probably were preventable and the board was working towards a system where it was possible to identify the exact number.
He admitted the sentinel events category was “probably ... too narrow” to provide the public and the board with the information it needed about avoidable incidents.
Dr Richmond said: “We clearly have events that are happening that are preventable.
“We are an organisation that has a clear ambition to be the safest hospital we possibly can. The way to do that is to interrogate your data, to share your data and to learn from your data.
“Are we an exemplary organisation? I am saying 100 per cent not. We are an organisation that has to reduce harm. That is in our quality improvement strategy.”
He added: “We have a system that is maturing and improving. I would like for our systems to be able to give us that data.”
Dr Richmond, who is responsible for quality of care at the hospital, pledged that BHB would publish its incident statistics twice-yearly on its website in the future.
He said: “Our aim is to be fully transparent. Really, as a consequence of you pushing and trying to get the information, we have said ‘why aren’t we putting our data on the website to allow the public to be informed?’ And we will.
“This is information we must be held accountable for and the public have a right to know it.”
As well as the information on reported adverse events for 2011 to 2015, BHB’s new figures provided more up-to-date statistics.
They show that between March 28, 2011 and May 31 this year, 5,483 adverse events were reported at KEMH, with the majority — 3,644 — involving no harm.
There were 663 events that did involve harm, with 41 incidents that fell into the three most serious categories of harm.
A total of 18 patients died unexpectedly, 8 patients needed life-saving treatment and 15 suffered permanent harm over the period.
There were 1,167 incidents where the severity level was unknown or not identified — it is not mandatory to assign a severity level.
There were also nine deaths which were “not caused by a safety event”.
Dr Richmond said after the incident log was reviewed, it was probable that the severity levels would have changed in only between 5 and 10 per cent of cases.
The Royal Gazette first asked BHB for statistics on “serious untoward incidents” at KEMH in the previous five years in September 2015.
The request listed terms which the events could have been recorded as — phrases used in healthcare to describe incidents involving avoidable harm, including “sentinel” and “adverse”.
The request was aimed at ensuring the broadest possible range of incidents was disclosed.
After BHB released information on only 13 events, The Royal Gazette asked for an internal review by Peter Everson, then the BHB chairman.
Mr Everson upheld the board’s decision, but The Royal Gazette appealed to the Information Commissioner’s Office.
The latest disclosure followed a request from the ICO to BHB as part of a negotiated resolution.