Review Question - QID 217611

This patient who suffered a urinary tract infection due to a retained Foley catheter that could have likely been avoided if the catheter was replaced at regular intervals most likely suffered a preventable adverse event.

An adverse event is any form of harm that comes to a patient as a result of medical or surgical treatment. These events can broadly be divided into preventable adverse events, which occur due to an error in medical treatment or a failure to follow optimal standards of treatment, and non-preventable adverse events, which occur despite adherence to the best available treatment evidence. Preventable adverse events therefore represent the harms that can be avoided by adherence to evidence-driven guidelines at an individual or a system level. For example, a well known intervention for improving patient outcomes is regularly changing Foley catheters to prevent urinary tract infections and removing the catheter as soon as no longer indicated.

Rodziewicz et al. present a review article on the types of medical errors and harm that can occur to patients. They discuss how preventable adverse events are unintended injury, prolonged hospitalization, or physical disability that occurs to a patient as a result of medical error.

Incorrect Answers:
Answer 1: Malpractice is improper, reckless, or illegal activity by a medical practitioner that results in patient harm. In this case, the error occurred due to an inadvertent omission rather than the deliberate action of a provider. If the provider was aware of the Foley but chose not to change it, then malpractice may have occurred.

Answer 2: A near miss is defined as any error or event that could have resulted in an adverse event occurring to a patient, but did not actually result in harm. In this case, the patient was harmed by the error in losing track of the Foley, resulting in an infection.

Answer 3: Negligence describes failure of a healthcare provider to meet the standard of care provided by an average qualified provider. In this case, the failure of the provider to track the Foley is a mistake that other providers may have also committed in this system given the lack of automatic alerts.

Answer 4: Non-preventable adverse events are harms that occur to patients despite adherence to the best available treatment evidence. In this case, harm likely would not have occurred if the Foley had been changed regularly.

Bullet Summary:
Preventable adverse events occur due to an error in medical treatment or a failure to follow optimal standards of treatment.