**Clinical vignette**

*Mrs. M, a fit 69-year-old, underwent an uncomplicated elective laparoscopic cholecystectomy [1]. The next morning (Day-1), upon review by the surgical team, it was decided that she should remain for* 

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*overnight observation due to some shoulder tip pain and nausea. That afternoon, she was transferred without the consultation of the surgical team from the surgical ward to a low dependency rehabilitation unit. By the following morning (Day-2), she was tachycardic, diaphoretic and had a distended abdomen. The ward medical officer reviewed Mrs. M and prescribed intravenous (IV) fluids and analgesia, ordered blood tests, and requested an urgent surgical review. The surgical team then saw Mrs. M as part of their usual morning ward round, and she still had generalised abdominal tenderness and abnormal vital signs. An abdominal X-ray and CT scan were ordered.*

• nurses, doing the right thing, taking the observations and notifying the medical staff,

clinical scenario like Mrs. M's,

by phone and

is designed to fail them.

**1. Introduction**

• interns with little knowledge and even less experience (too much time at med school learning ALS and CPR, but not enough time with real sick patients) of acutely deteriorating patients and certainly not enough emotional intelligence to manage all the players in a

Adverse Events in Hospitals: "Swiss Cheese" Versus the "Hierarchal Referral Model of Care and…

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• a surgical registrar who would have all the competencies, but is too busy to attend the patient and direct the care at the bedside and instead delegates tasks to the interns above

• a consultant surgeon with the skill and ability to fix the problem but most commonly employed only on a sessional basis, so often not actually there in the hospital in question.

So, at four levels above in the traditional hierarchal referral model of care, everyone is doing the right thing. CFC is the explanation for all this activity, whilst appropriate for the individual practitioner concerned was not sufficient to get Mrs. M to theatre more urgently to have the problem fixed. In addition to the CFC, we have become accustomed to the naïve expectation that some sort of track and trigger system (Medical Emergency Team, Rapid Response System) will fix the problem by getting the patients deterioration alerted. However, that is all they do. The rest is up to the clinicians on the ground to make the right diagnosis, determine the level of severity of the condition, initiate management, notify the right people and with all pressures of the job to do this in a timely fashion to prevent patient catastrophe [4, 5]. All too often, it is only patient physiological reserve that defends patients from a system of care that

The first chapter in this series of Patient Safety Vignettes [6] gives an overview of adverse events in health care and provides a standardised glossary of the various definitions that are used. An adverse event is defined as an injury resulting from a patient's medical management rather than a consequence of the patient's underlying medical condition or conditions [6–10]. Adverse events are common and costly to both the affected patients and the healthcare system [6, 11–18]. In the last two decades, the incidence, aetiology and outcomes from adverse events have been documented mostly in the hospital setting [6, 11–23]. Taking these studies together, approximately 10% of hospital patient admissions have some sort of adverse event. Of these, half result in no long-term harm to the patient. However, 10% (of the 10%, i.e., 1% of all hospital admissions) of the affected patients suffer significant harm such that they either die of or are left with some sort of permanent disability as a result of the adverse event (**Table 1**) [37]. In 1995, the cost of adverse events to the Australian health-care system was estimated at \$2 (AUD) billion dollars [8]. Attempts to reduce the incidence of adverse events and make hospitals safer have been largely unsuccessful [38–41]. Like other diseases and conditions, an understanding of the underlying aetiology or 'pathophysiology' of adverse events is important for the development of preventative strategies. To date, the predominant

*Mrs. M continued to deteriorate over the day. Another set of abnormal vital observations was taken sometime after the ward round, yet no doctor was informed. Mrs. M was seen by the two interns attached to the surgical unit. They were called to review her in the CT room due to concerning vital signs and contacted their registrar for assistance. They prescribed IV therapy and analgesia following their registrar's phone advice.*

*Upon discussion of the CT results between the consultant and registrar midday, it was decided that Mrs. M was to return to theatre later that day for explorative laparotomy, and then to transfer to ICU for post-operative observation. Mrs. M was therefore assessed by the intensivist on-duty who diagnosed peritonitis and renal failure, and prescribed triple antibiotics and rapid IV fluid therapy, and strict monitoring of fluid balance. She was concurrently seen by the anaesthetist on-duty for pre-anaesthetic assessment. As Mrs. M had single IV access, only one antibiotic was administered by the time she was called to the operating room.*

*Once in the operating theatre, surgery was delayed by an hour and ten minutes when Mrs. M becoming profoundly hypotensive upon anaesthetic induction. A bile leak was found intra-operatively and the abdomen lavaged. It was not discovered until her arrival in ICU later that evening that Mrs. M had only received one of the three prescribed antibiotics. By then, Mrs. M was severely septic, requiring inotropes, dialysis and mechanical ventilation. A second laparotomy, 2 days (Day-5) later found widespread bowel and hepatic ischaemia, and Mrs. M died the next day of multi-organ failure (Day-6).*
