The article by Vincent and colleagues is both salutary and helpful in
that it again draws attention to possible ways of improving practice.1 We
are concerned however that no mention has been made of what might be
called “no win” situations where there is a high chance of an adverse
event whichever course of action is pursued. As far as we can ascertain
from the “criteria for adverse events” no allowance is made for this and
indeed it is probably impossible to do so. However, it is important to
acknowledge such a problem when commenting on the findings.
Even in the example quoted there is an element of this dilemma.
Osteomyelitis as a complication of leg ulceration is probably quite rare,
whereas the alternative, apparently preferred option of more aggressive
management with antibiotics could have resulted in significant antibiotic-
induced complications.
Older people by virtue of the common problem of multiple pathologies
are particularly candidates for “adverse events”. Should you increase
treatment for cardiac failure in someone with a degree of renal impairment
and risk precipitating frank renal failure (adverse event of commission),
or risk them dying from undertreated cardiac failure (adverse event of
omission)?
Comparisons with civil aviation procedures seem popular in relation
to adverse events and risk reduction. Perhaps we could suggest “We are
flying a rather old and unreliable aircraft. Would you rather crash here
or there?”
David Griffith, Paul Diggory and Anand Mehta
Consultant Physicians - Care of Older People
1) Vincent C, Neale G and Woloshynowych M. Adverse events in British
hospitals: preliminary retrospective record review. BMJ 2001; 322: 517-9
(3 March)
Rapid Response:
Sometimes "adverse events" may be inevitable
Editor,
The article by Vincent and colleagues is both salutary and helpful in
that it again draws attention to possible ways of improving practice.1 We
are concerned however that no mention has been made of what might be
called “no win” situations where there is a high chance of an adverse
event whichever course of action is pursued. As far as we can ascertain
from the “criteria for adverse events” no allowance is made for this and
indeed it is probably impossible to do so. However, it is important to
acknowledge such a problem when commenting on the findings.
Even in the example quoted there is an element of this dilemma.
Osteomyelitis as a complication of leg ulceration is probably quite rare,
whereas the alternative, apparently preferred option of more aggressive
management with antibiotics could have resulted in significant antibiotic-
induced complications.
Older people by virtue of the common problem of multiple pathologies
are particularly candidates for “adverse events”. Should you increase
treatment for cardiac failure in someone with a degree of renal impairment
and risk precipitating frank renal failure (adverse event of commission),
or risk them dying from undertreated cardiac failure (adverse event of
omission)?
Comparisons with civil aviation procedures seem popular in relation
to adverse events and risk reduction. Perhaps we could suggest “We are
flying a rather old and unreliable aircraft. Would you rather crash here
or there?”
David Griffith, Paul Diggory and Anand Mehta
Consultant Physicians - Care of Older People
1) Vincent C, Neale G and Woloshynowych M. Adverse events in British
hospitals: preliminary retrospective record review. BMJ 2001; 322: 517-9
(3 March)
No competing interests
Competing interests: No competing interests