AVOIDABLE HARM

Joseph E Ibrahim PhD, FRACP, FAFPHM

Health Law and Ageing Research Unit, Department of Forensic Medicine

CRE-Patient Safety, Department of Epidemiology & Preventive Medicine

WHAT DO WE KNOW ABOUT AVOIDABLE HARM?

� What do you know?

� What do your colleagues know?

� What do you think I know?

LEARNING

� Pre-test

� Interruption

� Environment chaotic

� Cramming or moderate multiple trials

WEBSITES

� Driving and Dementia <

http://www.youtube.com/watch?v=4F9z8mPhcTw&feature=youtu.be>

� NFR and Dementia http://www.youtube.com/watch?v=4ps03E-NCaI

MEASURABLE

� Death

� Cause of death

� Premature

� Preventable

� Dignity of risk

THE SCIENCE?

� Ibrahim JE1, Murphy BJ1, Bugeja L1, Ranson D12. Nature and extent of

external-cause deaths of nursing home residents in Victoria, Australia. J Am

Geriatr Soc. 2015 May;63(5):954-62. doi: 10.1111/jgs.13377. Epub 2015 May 4.

THE ABSTRACT

� OBJECTIVES:

• To describe the nature and extent of external-cause deaths of residents of nursing homes in Victoria, Australia.

� DESIGN:

• A retrospective cohort study of all decedents using routinely collected data contained within the National Coronial Information System.

� SETTING:

• Accredited nursing homes in Victoria.

� PARTICIPANTS:

• Nursing home residents who had died from external causes and whose deaths were reported to the Coroners Court between July 1, 2000, and December 31, 2012.

� MEASUREMENTS:

• Basic descriptive analysis was conducted to measure frequencies and proportion of exposures within each outcome group, and rates were calculated using population data.

ANY INTEREST?

� Nature and extent of external-cause deaths of nursing home ...

• www.ncbi.nlm.nih.gov/pubmed/25940003 by JE Ibrahim - 2015 - Cited by 1 - Related articles

• May 4, 2015 - Nature and extent of external-cause deaths of nursing home residents in Victoria, Australia. Ibrahim JE(1), Murphy BJ(1), Bugeja L(1), Ranson ...

� Victorian nursing home deaths preventable: study - The Age

• www.theage.com.au/.../victorian-nursing-home-deaths-preventable-study-2...

• May 17, 2015 - Research shows 89% of preventable deaths in nursing homes are ... life is worth something no matter how old you are," Professor Ibrahim said.

� Study into nursing home deaths, Monash University

• monash.edu/news/show/study-into-nursing-home-deathsCached

• May 18, 2015 - Professor Ibrahim said the greater incidence of falls related deaths in the nursing home population compared to the general community was ...

� Too many preventable nursing home deaths: study | 6minutes

• www.6minutes.com.au › News › Latest NewsCached

• May 19, 2015 - Most premature deaths in nursing homes are from falls, according to ... The study, led by Professor Joseph Ibrahim, shows 7% of deaths were ...

WHY SO MUCH.. .SO LITTLE?

� Falls most common cause of early deaths in nursing homes ...

• www.heraldsun.com.au/...deaths...nursing-homes.../story-fngnvmhm-1227...

• May 20, 2015 - Professor Joseph Ibrahim, who led the study, said the physical frailty of ...

The study found seven per cent of premature nursing home deaths ...

� Study into nursing home deaths - SeniorAu

• www.seniorau.com.au/...seniorau.../5575-study-into-nursing-home-death...Cached

• May 31, 2015 - Professor Ibrahim said the greater incidence of falls related deaths in the

nursing home population compared to the general community was ...

� Study into nursing home deaths | DPS News

• https://news.agedcareguide.com.au/.../study-into-nursing-home-deaths/Cached

• May 28, 2015 - Professor Ibrahim says the greater incidence of falls related deaths in the

nursing home population compared to the general community is likely ...

THE SCIENCE PART 2

� RESULTS:

• One thousand two hundred ninety-six external cause deaths of nursing home residents were identified.

• Deaths were due to falls (n=1,155, 89.1%), choking (n=89, 6.9%), suicide (n=17, 1.3%), complications of clinical care (n=8, 0.6%) and resident-on-resident assault (n=7, 0.5%).

• Deaths occurred more frequently in women (n=814, 62.8%), in keeping with the sex distribution in nursing homes, and residents aged 85 and older (n=923, 71.2%).

• The number of inquests held to investigate a death as a matter of public interest was small (n=24, 1.9%).

� CONCLUSION:

• A significant proportion of nursing home resident deaths are from external causes and are potentially preventable.

• A shift in community attitudes is required toward an understanding that premature death of a resident from injury is not a natural part of life.

WHAT DID WE LEARN?

� Song title, new musical appreciation

� Learning

� Avoidable harm

� About the presenter? Or the seminar organisers?

� About society?

� Anything else