Adverse events related to coordination between primary and secondary health care services in Norway
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At present, nearly 25 percent of all patients experience some variety of adverse event during the life cycle of their patient experience in a hospital admission (Kable, et al. 2008). It is critical to effectively gain a comprehensive understanding of the types, frequencies, causes and consequences of adverse events related to coordination of care between primary and specialized health care services in Norway, in order to effective prevent future adverse events. This research seeks to determine the primary characterizations of adverse events, as they relate to patient transfers between care providers, as well as to identify details and additional areas for research associated with these characterizations. The research was accomplished through review of adverse event reports using a developed taxonomy to appropriately sort and present event occurrences. Within the findings were a number of significant results, including a higher propensity for errors associated with improper or inadequate communication, caused by multiple causal factors. In utilizing a number of existing taxonomic structures to sort, evaluate and classify adverse events, it became apparent that there is no existing taxonomy that is fully suited to apply to patient handovers occurring between primary and specialized health care providers in Norway, resulting in the need to develop one. Additionally, resulting data supported a need for further research and development of best-practice defensive barriers to mitigate hazards within patient handovers and care transfers, to better protect against multifactorial risks associated with typical adverse events.
Master's thesis in Health and social sciences