Current health care is not as safe as it should be. In the current issue of Deutsches Ärzteblatt International (Dtsch Arztebl Int 2010; 107: 92-9), Barbara Hoffmann and Julia Rohe explain the reasons for adverse events, as well as measures to ensure better patient safety.
Treatment can make you ill. The German Coalition for Patient Safety (Aktionsbündnis Patientensicherheit) estimates that about 17,000 deaths per year in Germany are due to preventable adverse events. Adverse events are all harms occurring during patient care which are not due to the underlying disease. The authors discuss problem areas in inpatient and outpatient care. For example, shift work in hospitals necessitates complex organization of the work and numerous planning and communication processes. Information may get lost at each interface. In addition, hand hygiene is not always optimal and there may be errors in drug supply. Most patients are treated as outpatients. Errors in diagnosis are possible here, monitoring is more difficult, and there is no common patient file for all physicians involved. The actual rate of preventable adverse events is a controversial issue. The authors advise careful consideration, consistent disclosure, and systematic error analysis.