Health Care Adverse Event Investigations Expert Article

In this article, the health care experts discuss the process by which adverse medical events are evaluated by medical professionals and forensic experts. The article describes the concept of an adverse event and provides two models that are used to evaluate the quality of care and preventability of a specific incident.

The experts at Robson Forensic are frequently retained to investigate adverse events within health care and other managed care settings. Our experts approach these investigations from the perspectives of nurses, physical therapists, and other direct care professionals. We also have experts who specialize in the operations and administration of nursing homes, hospitals, and managed care facilities.

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Evaluating Adverse Health Care Events and the Adequacy of Care

The Office of Inspector General describes an adverse medical event as harm to a patient or resident as a result of medical care, including the failure to provide needed care. “Adverse events include medical errors but they may also include more general substandard care that results in patient or resident harm, such as infections caused by the use of contaminated equipment. However, adverse events do not always involve errors, negligence, or poor quality of care and are not always preventable.”1

Adverse health care events can be categorized as either preventable or non-preventable based on a number of factors related to the care provided. In one example, a negative outcome may be considered preventable if a resident’s heath status was not adequately assessed. In another, an event may have occurred despite proper assessment and procedures being followed.

The evaluation of adverse health care events is comprehensive. It must be performed consistently, systematically, and in accordance with established standards in order to provide reliable data that is meaningful for measuring and improving the quality of care.

There are a variety of tools available for facilities to identify, track, and investigate adverse events. In this article, the health care and human services experts at Robson Forensic review two models that can be used in the evaluation of adverse events.

Adverse Events

The term Adverse Event covers a wide range of maladies, and can be used to describe anything from an abrasion to death. Our experts are generally retained in cases where the adverse event results in severe or life threatening complications or death.

Examples of typical health care investigations include:

  • Abuse/Neglect
  • Falls
  • Elopement
  • Pressure Injury
  • Unexplained Injuries/Fractures
  • Burns
  • Sepsis
  • Infections
  • Infestations
  • Medication Events
  • Suicide
  • Unexplained death

Evaluating the Adequacy of Care

When providing care, health care and human services professionals use specific processes to assess patients/individuals and develop care plans that address the specific needs of each person. Forensic health care and human services experts utilize similar processes to determine if a person’s plan of care was appropriate and properly followed. The care cycle depicted in figure 1 is one example of a process utilized by industry professionals and forensic experts alike.

Sometimes referred to as the care cycle, the patient/individual care process includes performing assessments, identifying and evaluating risks, implementing and monitoring interventions, evaluating interventions for effectiveness, and making changes to the plan of care as necessary. The process repeats throughout a patient/individual’s treatment to address changing needs and conditions. The care cycle includes multiple workers, known as the interdisciplinary team, which should be involved throughout the process.

As part of a forensic investigation, health care and human services experts will frequently evaluate the totality of care, including the effectiveness to which professionals developed, implemented and revised the plan throughout the person’s treatment. A review of the initial assessments is critical; this review can include determining if the assessments were timely, complete, and accurate. The next step is to determine if potential risks were identified and analyzed in such a way to identify potential obstacles and limit the risks. In line with the care cycle, the next step is to evaluate if appropriate interventions were developed and implemented to address the individual needs of the patient. The process does not end here, as the forensic investigator must evaluate the way in which interventions were monitored and evaluated for effectiveness, and the appropriateness with which the plan of care was adjusted to satisfy the changing needs of the person. Experts will look to see that each step in the care cycle was properly completed with appropriate involvement from the interdisciplinary team.

After reviewing the patient/individual care process a health care or human services expert can better determine if an adverse event was preventable or non-preventable.

Evaluating the Preventability of Events

Evaluation of the care process provides the foundation of knowledge required to determine if an adverse event was Preventable or Non-Preventable. However, not all events are foreseeable or preventable, and adverse events can occur despite high quality of care.

Preventable Events

Some factors that contribute to an event being classified as preventable include substandard treatment, inadequate monitoring, and failing to provide treatment. An event may be considered preventable if during an investigation it is determined:

  • the person’s health status was not adequately assessed
  • necessary treatments were not provided
  • appropriate treatments were provided in a substandard way
  • an error was made related to medical judgment, skill, or resident management
  • the person’s care plan was inadequate
  • the person’s progress was not adequately monitored
  • there was poor communications within the interdisciplinary team
  • there was a flawed safety system
  • there was a breakdown in environment

Non-Preventable Events

Not all events are foreseeable or preventable. Some things to consider when determining if an event was non-preventable include:

  • the event occurred despite proper assessment and procedures being followed
  • the person’s diagnosis was unusual or complex
  • the person was highly susceptible to event because of health status
  • the caregiver could not have anticipated the event given information available

Unable to Determine

There are occasions an adverse event occurs and it cannot be determined as preventable or non-preventable. The factors that contribute to this include:

  • poor or absent documentation
  • the person’s medical care being complex
  • the person’s conditions being complex

After the relevant medical information has been gathered and reviewed, medical professionals and forensic experts analyze the data to determine if an event was preventable. The decision algorithm shown below (Figure 2) is based on processes prescribed by the Office of Inspector General and represents one model that health and human service care experts use to determine the preventability of an adverse event.

The preventability of an event involves determining if the provider identified and documented the failure, if the failure could have been anticipated, if precautions were taken to prevent the failure, and how frequently the failure occurs. Our experts perform these analyses frequently and can correctly evaluate the relevant facts of an adverse event and analyze whether appropriate care was provided to the patient/individual in your case.

Forensic Health Care Investigations

The health care and human services experts at Robson Forensic can address the adequacy of care provided in hospitals, nursing homes and other acute, rehabilitation, long term, outpatient or residential health care facilities. The scope of our investigations will frequently involve an evaluation of administrative policies and procedures, the level of care provided by health care professionals, or the maintenance and custodial practices of care facilities.

For more information submit an inquiry or visit our Health Care practice page.




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