Selected risk factors for adverse events in hospitalised patients in healthcare facilities

INTRODUCTION

The concept of adverse events in hospital care has become a key focus of research in the context of patients’ safety in recent years. It is an important and indispensable element of the quality of medical services provided by healthcare providers. High-quality medical services are characterised by medical, human, infrastructural, and financial resources organised in an efficient manner [1]. A breakthrough in the interest in the issue of adverse events occurred in the 1990s. It was understood that despite the development of medicine and the possibility of treating many incurable dis-eases, extending life expectancy, there is a risk of failing to provide adequate safety to patients in medical institutions. For every person, safety is a basic need. Every hospitalisation carries the risk of an adverse event. Hence, the issue of patient safety and adverse events has become the subject of much analysis and research. In 1999, the Committee on Quality of Medical Care in America, Institute of Medicine issued a report entitled “To Err Is Human. Building a Safer Health System”, which shocked the public with its content [2]. It provides a comprehensive analysis of the problem of error generation in the health care chain and shows various methods of prevention. The paper showed data indicating that numerous medical errors were responsible for between 44,000 and 98,000 deaths per year in the United States. The publication indicated that the predominant cause of medical errors was not negligence, or lack of knowledge or skills of medical personnel, but inadequacies in the health care system [3].
The aim of this report is to present selected risk factors for adverse events among inpatients in medical facilities.

ADVERSE EVENTS AND RISK FACTORS

An adverse event according to the Joint Commission for Accreditation of Healthcare Organisations (JCAHO) is harm that occurs during diagnosis and/or treatment that is unrelated to the underlying disease, condition, or risk. This is also the definition provided by the World Health Organization (WHO), adding that an adverse event is understood to be un-intended or unexpected [4]. According to the Institute of Medicine, an adverse event is defined as any type of action that results in harm, such as death, life-threatening illness, disability, prolonged hospital stay, etc., resulting from a medical intervention that caused harm to a patient [5]. On the other hand, according to the definition adopted by the Centre for Monitoring Quality in Health Care in its accreditation standards, an adverse event is a defect caused by treatment that is unrelated to the natural course of the disease, the patient’s condition, or the risk of occurrence [6].
It is estimated that there are more than 420 million hospitalisations worldwide each year, of which more than 47 million are accompanied by adverse events. The WHO reports that approximately 134 million hospitalisations occur each year in low- and middle-income countries [7-9]. In Poland, which, according to the World Bank, is one of the high-income countries, the number of adverse events is still not fully known, because there is no uniform system for reporting and recording these events. Facilities are not required to register them [9]. According to information from the Patient Ombudsman, in January 2022, patients and their families reported 125 adverse events during hospitalisation [10]. A study by the Centre for Monitoring Quality in Healthcare, on the other hand, indicates that adverse events occur in 7.2% of all hospitalisations in Poland, of which 47.37% could have been prevented [6].
Risk factors are, according to circumstances, legal status, facts, actions, inactions, and external and internal events that may but do not necessarily cause a risk of irregularity. These are the causes of the risk. They increase the likelihood of a given adverse event occurring. The WHO groups risk factors into the following categories:
• Demographic (directly related to the population), e.g. age, gender, educational level, socio-economic status;
• Physiological (related to the body), e.g. high blood pressure, low albumin, high glucose, obesity;
• Behavioural (related to behaviour), e.g. poor diet, smoking, alcohol abuse;
• Environmental (these are physical, biological, economic, social factors), e.g. air quality, availability of sanitation;
• Genetic (resulting from having specific genes or genetic mutations), e.g. diseases caused by genetic inheritance in the family [11-14].
An analysis of the literature shows that adverse events have many different risk factors. This gives grounds to conclude that the topic of risk factors for events is a very broad one, as studies show factors on the part of those providing direct patient care, e.g. the error of the person performing the procedure and those providing indirect care – including organisational, management errors, external factors relating to the medical equipment used in patient care, systemic errors, and key risk factors relating to the patient. The latter are the focus of this research.
Among the non-patient-related risk factors most frequently cited by the authors are the following: the high level of complexity of the treatment process, potential latent inadequacies in health care delivery systems, the disparity between advances in medical knowledge and technology and opportunities for continuous training of medical staff, the general frailty of human nature, the state of health and the fitness of medical staff, and cognitive errors due to the specific functioning of the human brain and sensory organs [15]. The risk of incidents is also related to the unreliability of the medical staff, the presence of conflicts within the team, inadequate interpersonal communication, or faulty medical equipment. Non-ergonomic technical or systemic solutions, e.g. failure to adjust minimum staffing standards to the number of hospitalised patients and the category of nursing care set for patients, can also result in an increased risk of adverse events [16]. What is more, the working conditions and organisation of the medical staff, as well as errors hidden in the system or management of a particular unit, affect the risk of adverse events. Usually, the medical staff are mistakenly blamed for the event, but in many cases the cause may lie elsewhere. Those related to the person taking care of patients may be due to medical staff fatigue through excessive working hours and staff shortages [17].
Another group of risk factors are those relating to the patient – their age, gender, and health status, i.e. underlying disease, co-morbidities, medications taken (type and amount). Risk factors also include the presence of disorders that limit/hinder the patient’s daily functioning, i.e. visual impairment, memory impairment, hearing impairment, or balance impairment. The risk of adverse events may be caused by one of the patient’s predominant factors or a combination of factors. In addition, extrinsic factors that depend on the nature of the diagnostic, therapeutic, or nursing interventions may also be involved [18].
Grochans et al., in their studies on the adverse event of falls, indicated that it results from a complex set of factors acting simultaneously. It is not usually the effect of a single causal factor. In their study, the authors considered both intrinsic and extrinsic factors, as well as situational circumstances such as the type of activity being performed at the time of the fall. They concluded that the number of falls is mainly influenced by modifying internal risk factors [19]. Aranaz-Andrés and his team, in a study conducted in Spanish hospitals, noted that among patients with intrinsic risk factors, adverse effects occurred in 13.2%, compared with 5.2% of patients who did not have these factors. According to these researchers, adverse effects were therefore more frequent in patients with intrinsic risk factors than in those without these factors [20]. To encapsulate the complex topic of risk factors affecting patient safety, Table I summarises them, giving characteristics and justification with reference to the scientific publications that have addressed the risk of adverse events [11, 19, 21-58].

SUMMARY AND CONCLUSIONS

Despite huge interest in the issue of adverse events, advances in medicine, and numerous studies and publications, the topic of adverse events continues to be a problem in many healthcare settings around the world. Poland still lacks a structured system for reporting events and, consequently, specific data on the incidence, prolongation of hospitalisation, and increased costs of treatment and care associated with an adverse event. The magnitude of the incidence problem is not fully understood due to many systemic deficiencies still present in individual countries. Therefore, the epidemiological data are highly variable.
Intrinsic risk factors such as the patient’s health status, age, medications used, length of hospitalisation, medical procedures, and nutritional status can influence the likelihood of these events occurring. Identification of the incidence, risk factors, and characteristics of adverse events in healthcare is essential to recognise the magnitude of the problem, as well as to propose strategies to mitigate the occurrence of new adverse events and to improve the quality of safety of hospitalised patients [59, 60]. Depending on the types of adverse events analysed, the available research findings on risk factors differ. Therefore, expanding research in this area would help to characterise and attribute relevant risk factors to the types of adverse events that may occur during a patient’s stay in a medical facility. However, it is important to remember that each patient is an individual, and the risk of adverse events may vary depending on a number of factors. That is why it is important to take an individual approach to each patient and monitor the condition regularly. Ensuring patient safety by reinforcing the prevention of adverse events has a positive impact on the hospitalisation of patients. Understanding internal risk factors can help prevent adverse events and improve the quality of healthcare.

Disclosures

The authors declare no conflict of interest.
This research received no external funding.
This study was approved by the Bioethics Committee of the Jagiellonian University Medical College (Approval No. 1072.6120.42.2022).

References