Nursing Inquiry. 2019;00:e12298. wileyonlinelibrary.com/journal/nin
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https://doi.org/10.1111/nin.12298
© 2019 John Wiley & Sons Ltd
1 | INTRODUCTION
Adverse health care events are defined as medical injuries caused
by medical management, including all aspects of care, rather than by
the patient's underlying disease. Adverse events have recently been
estimated to be the 14th leading cause of morbidity and mortality
in the world's population and are known to be a global public health
issue (Jha et al., 2013; World Health Organization, 2005). Overall,
one in 10 patients suffers from a hospital‐acquired condition, such
as hospital‐acquired infections, pressure injuries, and falls (National
Patient Safety Foundation, 2015). In Sweden, 12.3% of all admis‐
sions to hospitals are related to at least one adverse event, and esti‐
mates show that 7.5% of these could have been prevented (Swedish
Associations of Local Authorities & Regions, 2018). The focus on
patient safety, that is, ‘the reduction of risk of unnecessary harm as‐
sociated with health care to an acceptable minimum’ (World Health
Organization & WHO Patient Safety, 2010, p. 15) and measures
taken internationally to diminish suffering, the number of deaths,
and costs to society have increased, particularly after the Institute
of Medicine published the report To Err Is Human (Kohn, Corrigan,
& Donaldson, 2000). However, patient safety efforts have not pro‐
gressed as quickly as anticipated and have recently been acknowl‐
edged to be a more complex area than expected, with large gaps in
knowledge remaining globally (National Patient Safety Foundation,
2015; Pronovost, Cleeman, Wright, & Srinivasan, 2016; World Health
Organization et al., 2008). How unsafe patient care is discussed and
thought about depends on a diversity of contexts and perspectives,
which creates opportunities for a diversity of actions, all of which
Received: 10 December 2018
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Revised: 2 May 2019
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Accepted: 9 May 2019
DOI: 10.1111/nin.12298
FEATURE
Written reports of adverse events in acute care—A discourse
analysis
Anna Gyberg
1,2
| Ingela Henoch
1,3
| Margret Lepp
1,4,5
| Helle Wijk
1,6,7
|
Kerstin Ulin
1,2
1
Institute of Health and Care
Sciences, Sahlgrenska Academy, University
of Gothenburg, Gothenburg, Sweden
2
Department of Medicine, Geriatrics and
Emergency Care, Sahlgrenska University
Hospital, Gothenburg, Sweden
3
Angered Hospital, Gothenburg, Sweden
4
Østfold University College, Halden, Norway
5
School of Nursing and Midwifery, Griffith
University, Brisbane Queensland, Australia
6
Department of Quality
Assurance, Sahlgrenska University Hospital,
Gothenburg, Sweden
7
Center of Health Care
Architecture, Chalmers University,
Gothenburg, Sweden
Correspondence
Anna Gyberg, Sahlgrenska University
Hospital, Diagnosvägen 11, 41685
Gothenburg, Sweden.
Email: anna.gyberg@vgregion.se
Funding information
We are grateful to The Swedish Health Care
Facilities Network and the foundation of
Hjalmar Svensson, which have supported
this study with grants.
Abstract
Adverse health care events are a global public health issue despite major efforts,
and they have been acknowledged as a complex concern. The aim of this study was
to explore the construction of unsafe care using accounts of adverse events con‐
cerning the patient, as reported by patients, relatives, and health care professionals.
Twenty‐nine adverse events reported in an acute care setting in a Swedish university
hospital were analyzed through discourse analysis, where the construction of what
was considered to be real and true in the descriptions of unsafe care was analyzed. In
the written reports about unsafe events, the patient was spoken of in three different
ways: (a) the patient as a presentation of physical signs, (b) the patient as suffering
and vulnerable, and (c) the patient as unpredictable. When the patient's voice was
subordinate to physical signs, this was described as being something that conflicted
with patient safety. The conclusion was that the patient's voice might be the only sign
available in the early stages of adverse events. Therefore, it is crucial for health care
professionals to give importance to the patient's voice to prevent patients from harm
and not unilaterally act only upon abnormal physical signs.
KEYWORDS
adverse event, adverse health care event, discourse analysis, patient safety, unsafe care