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47
Outcomes of the peer review
7.9.
A primary objective of the VASM peer review process is ascertaining if death was a direct result of the disease
process alone, or if aspects of patient management might have contributed to that outcome. There are two possible
outcomes: either death was a direct outcome of the disease process and the clinical management had no impact on
the outcome, or there was a perception that aspects of patient management may have contributed to the death of the
patient. In cases in which there is a perception that the clinical management may have contributed to death, the VASM
has specified a spectrum of criticism from which the assessor can choose, as outlined below.
•
An area for
consideration
exists: the assessor believes an area of care
could
have been improved or different,
but recognises that the issue is perhaps debatable. It represents very minor criticism.
•
An area of
concern
exists: the assessor believes that an area of care
should
have been better.
•
An
adverse event
occurred: this is defined as an unintended injury or event that was
caused
by the medical
management of the patient rather than by the disease process, and which was sufficiently serious to lead to
prolonged hospitalisation, or to temporary or permanent impairment or disability of the patient at the time of
separation, or which contributed to or caused death.
Figure 29: Clinical management issues as identified by assessors.
Note: total n= 6,179 cases.
Audit period 1 July 2007 to 30 June 2015.
Data not available: n=21 (<1%).
Comments:
•
65.2% (4,026/6,179) of cases had no identified clinical management issues.
•
Minor issues of patient management were perceived to have occurred in 19.8% (1,221/6,179) of cases.
•
Areas of concern were identified in 9.1% (561/6,179) of cases.
•
In 5.3% (330/6,179) of cases assessors identified a clinical issue serious enough to be categorised as an adverse
event.
65.2%
19.8%
9.1%
5.3%
None Consideration Concern Adverse event
5.6%
Adverse events
2007-2014
5.3%
Adverse events
2014-2015