Academic journal article Australian Health Review

Peer Review of Adverse Events - a Perspective on Macarthur

Academic journal article Australian Health Review

Peer Review of Adverse Events - a Perspective on Macarthur

Article excerpt


Recent investigations into the Macarthur Health Service have resulted in multiple reviews of a small number of cases. This article was prompted by a casual observation that these reviews have resulted in differing conclusions about what occurred in each case and what might have been done in response. The reliability of peer review is examined, together with the literature on the scale of adverse events and the issue of problem identification. Potential sources of bias and error during peer review are considered. Drawing on the lessons from the literature and the experience of Macarthur, suggestions are made to improve the identification and review of adverse events.

Aust Health Rev 2004: 28(1): 26-33

THIS ARTICLE EXAMINES the issues of adverse events and peer review by reflecting on recent investigations of the Macarthur Health Service (MHS), the available literature and my experience as a senior manager in the health service between 1998 and 2003. The investigations required reconstruction and interpretation of past events at both the individual and system levels and the catalyst for this article was a simple observation that the reviewers of the incidents seemed to arrive at different conclusions regarding what had occurred. One reviewers conclusion of 'poor assessment' was another reviewers conclusion of a 'communication problem'; one reviewer's 'adverse event' was another reviewer's 'inevitable consequence of a disease process'.

In November 2002, four nurses went to the NSW Health Minister with a broad range of allegations centred on poor clinical care and various human resource management issues. The allegations were investigated by the NSW Health Care Complaints Commission (HCCC) which reported its findings and recommendations in December 2003. Subsequently, the head of the HCCC was dismissed by the NSW Health Minister and a new investigation commenced the Special Commission of Inquiry into Campbelltown and Camden Hospitals (SCI). Additional inquiries have also been undertaken by the Upper House of the NSW Parliament and the Independent Commission Against Corruption.

The HCCC investigated 47 incidents, many of which had already been reviewed by staff of the MHS, by establishing a series of clinical review panels. The SCI also reviewed the incidents, resulting in referral of doctors and nurses to their respective registration authorities.

This article examines what is known about the process of reviewing clinical cases and the confidence that can be placed in the outcomes. The starting point was the available literature on peer review and the major studies in Australia and elsewhere that have examined the scale of adverse events.

Adverse events

The pioneering work on medical adverse events was the Harvard Medical Practice Study (HMPS), published in 1991, that identified adverse events in 3.7% of hospital admissions, with 27.6% of the adverse events assessed as being due to negligence, and close to 14% of the adverse events resulting in death (Brennan, Leape et al. 1991; Leape et al. 1991). The adverse events were not randomly distributed, with certain types of hospitals found to have higher rates (Brennan, Hebert et al. 1991). The HMPS was replicated in Utah and Colorado with similar results - adverse events occurred in 2.9% of hospital admissions (Thomas, Studdert et al. 2000a).

The best available evidence regarding adverse events in Australia comes from the Quality in Australian Health Care Study (QAHCS), published in 1995. A review of over 14000 admissions to 28 hospitals in New South Wales and South Australia identified a much higher level of adverse events than the American studies, with 16.6% of admissions associated with an adverse event resulting in disability or longer hospital stay for the patient (Wilson et al. 1995).

An examination of the different adverse event rates in the American and Australian studies concluded that the higher Australian rate was at least due in part to methodological differences, with the Amencan studies defining adverse events more stringently (Runciman et al. …

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