A Quantum Leap for Investment in Patient Safety - Dr ：医生在病人安全投资的量子飞跃.doc

A QUANTUM LEAP FOR INVESTMENT IN PATIENT SAFETY: A LEGAL MORAL DUTY A PAPER BY SIMON JOHN AND MICHAEL POWERS QC SEPTEMBER 2011 ? 1. CONTENTS CHAPTER/ Para No. TITLE OF THE CHAPTER/ Paragraph PAGE No. 2. EXECUTIVE SUMMARY 7 3. INTRODUCTION 14 4. THE EXTENT OF INJURY TO PATIENTS IN ENGLISH NHS HOSPITALS 4.1 The English benchmark epidemiological evidence 16 4.2 Outcomes of medical adverse events 17 4.3 Parliamentary Reliance 18 4.4 Other medical adverse events data 18 4.5 These fatalities in context 19 4.6 Studies by Specialty 20 4.6.1 Hospital Acquired Infections 21 4.6.2 Venous Thromboembolisms 21 4.6.3 Surgery 22 4.6.4 Care for the Elderly 23 4.6.5 Adverse Drug Events 26 4.6.6 Intensive Care 27 4.6.7 Adverse Events in emergency departments 28 4.6.8 Obstetrics 28 4.7 Safety Ratings by Dr Foster 31 4.8 The number and cost of claims by specialty 31 4.9 International comparative data for adverse events 34 4.10 Comment 35 5 THE CAUSES OF MEDICAL ADVERSE EVENTS 5.1 Systemic causes 35 5.2 Bupivacaine and vincristine 36 5.3 The Health Select Committee’s (“HSC”) view 36 5.4 Detailed investigation rare 37 5.5 International Classification of Diseases Y40-Y84 38 5.6 Failure to Learn from mistakes 39 5.7 Comment 41 6 THE TOLERABILITY OF RISK 6.1 Introduction 41 6.2 Risk in Industry 41 6.3 The tolerable risk of death to a patient by a medical adverse event 45 7 THE COST OF MEDICAL ADVERSE EVENTS 7.1 The Distribution of the Cost of medical adverse events 47 7.1.1-5 Distribution of costs 48 7.2 The cost of medical adverse events to Clinicians 49 7.3 The cost of Medical adverse events to the NHS 50 7.3.1 The cost of Adverse Drug-Related Events (ADEs) 50 7.3.2 The cost of adverse Venous Thromboembolisms (“VTE”s) 50 7.3.3 The cost of Hospital Readmissions to the NHS 51 7.3.4 The cost of hospital acquired infections (HAIs) 51 7.3.5 The cost of additional bed days brought about by medical adverse events 52 7.3.6 Lifelong medical trea