New research shows that one in eight patients admitted to hospital during 2009 experienced adverse events. This is the first time such research has been carried out in Ireland and the figures are broadly consistent with baseline studies conducted in other countries.

The study, which was carried out by RCSI (Royal College of Surgeons in Ireland) in collaboration with the Royal College of Physicians in Ireland (RCPI), will be published today in the BMJ Quality & Safety Journal. It was funded by the Health Research Board (HRB) and the Health Service Executive (HSE).

An adverse event is an unintended injury or complication as a result of healthcare management that results in a prolonged hospital stay, disability at the time of discharge from hospital or death.

HSE National Director for Quality Improvement, Dr Philip Crowley said that the HSE commissioned this study to establish a robust baseline and approach that we could depend on. “To drive change and improvement you need to know where you stand. This study gives a clear picture of the situation in 2009, prior to the HSE establishing the national clinical programmes in 2010. These programmes offer the opportunity for multidisciplinary and multisite collaboration to improve patient safety.” 

Key Research Findings
The Irish National Adverse Event Study (INAES) is funded through the Research Collaborative in Quality and Patient Safety (RCQPS), a collaboration between the Health Research Board (HRB), the Health Service Executive (HSE) and the Royal College of Physicians of Ireland (RCPI). INAES findings show:

• Numbers: The study shows that one-in-eight patients (12.2%) experienced an adverse event as a result of hospital care in 2009. This is broadly in line with international figures where adverse events rates ranged from 3-17% of hospital admissions, depending on how each country defined adverse events. 
• Impact: Almost 7 in 10 of these were rated as having a mild to moderate impact on the patient (ranging from no physical impairment at discharge to moderate impairment but recovery within 6 months), a further 5% caused moderate impairment with disability lasting 6 to 12 months, 10% caused permanent impairment (disability lasting greater than a year), 11% the level of impairment was not recorded at the time of discharge and 7% contributed to death. Over 70% of the events were considered preventable.
• Type: The adverse events included: readmission with additional symptoms, hospital acquired infections, delayed diagnosis, and surgical adverse events. 
• Risk: Adverse event risk was higher in admissions for surgical procedures. 
• Cost: The estimated annual cost of adverse events in 2009 was €194 million.
• Age: The average age of patients with an adverse event was significantly higher than those without (61.8 years versus 55.4 years). There was an 18% increase in the risk of an adverse event with every 10 years added to the patient’s age. 
  Gender: No significant difference was reported between men and women in this study. 

Dr Crowley continued, “The research will bridge the gap between knowing something and doing something about it and provide a huge opportunity to immediately improve the quality of patient care in Ireland. Since the establishment of the clinical programmes there have been significant improvements in reporting of adverse events and with the advancements of technology we will see this continue to improve over the coming years. The HSE will continue to collaborate with the Health Research Board on future research on quality care.”

Commenting on the study results, Professor David Williams, Principal Investigator, RCSI said: “While this study was conducted in 2009, it is an important measure of the burden and impact of these events. The study gives an overview of the types of patient safety issues that have helped, and will continue to help, guide future interventions to improve patient safety. The World Health Organisation recommends committing to national patient safety action by using local data and efforts must continue to be made to establish a ‘reporting culture’ in Ireland.”

Dr Graham Love, Chief Executive of the Health Research Board commented: “Research will save lives when it is put into practice. The HRB funded this study to ensure that the approach taken to measure adverse events was right and in line with international standards. Now we have created the foundation, there is a huge opportunity to build on the success of the HSE clinical care programmes to improve patient care and enhance the way services are delivered.”

Professor Richard Costello Director of Research at the Royal College of Physicians of Ireland said: “Our role in collaborating on this landmark research study reinforces the RCPI commitment to improving real patient outcomes and underpinning the work of the National Clinical Programmes with an evidence base. This is the first of many high quality studies facilitated through the RCQPS that will build the research capacity and capability of clinicians in this area and will also help researchers’ to access health care settings.”

Read the full paper here.

The paper is also available from the RCSI repository.