What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents

PURPOSE

Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors.

SUBJECTS

We conducted a prospective cohort study of 228 adult inpatients on a medicine unit of a Boston teaching hospital.

METHODS

Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone 10 days after discharge about "problems,""mistakes," and "injuries" that occurred. Physician investigators classified patients' reports. We calculated event rates and used multivariable Poisson regression models to examine the factors associated with patient-reported events.

RESULTS

Of 264 eligible patients, 228 (86%) agreed to participate and completed 528 interviews. Seventeen patients (8%) experienced 20 adverse events; 1 was serious. Eight patients (4%) experienced 13 near misses; 5 were serious or life threatening. Eleven (55%) of 20 adverse events and 4 (31%) of 13 near misses were documented in the medical record, but none were found in the hospital incident reporting system. Patients with 3 or more drug allergies were more likely to report errors compared with patients without drug allergies (incidence rate ratio 4.7, 95% CI 1.7, 13.4).

CONCLUSION

Inpatients can identify adverse events affecting their care. Many patient-identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.

Beyond the medical record: other modes of error acknowledgment

BACKGROUND

Studies before and since the 1999 Institute of Medicine report have noted the limitations of using medical record reporting for reliably quantifying and understanding medical error. Quantitative macro analyses of large datasets should be supplemented by small-scale qualitative studies to provide insight into micro-level daily events in clinical and hospital practice that contribute to errors and adverse events and how they are reported.

DESIGN

The study design involved semistructured face-to-face interviews with residents about the medical errors in which they recently had been involved and included questions regarding how those errors were acknowledged.

OBJECTIVE

This paper reports the ways in which medical error is or is not reported and residents' responses to a perceived medical error.

PARTICIPANTS

Twenty-six residents were randomly sampled from a total population of 85 residents working in a 600-bed teaching hospital.

MEASUREMENTS

Outcome measures were based on analysis of cases residents described. Using Ethnograph and traditional methods of content analysis, cases were categorized as Documented, Discussed, and Uncertain.

RESULTS

Of 73 cases, 30 (41.1%) were formally acknowledged and Documented in the medical record; 24 (32.9%) were addressed through Discussions but not documented; 19 cases (26%) cases were classified as Uncertain. Twelve cases involved medication errors, which were acknowledged in different categories.

CONCLUSIONS

The supervisory discussion, the informal discussion, and near-miss contain important information for improving clinical care. Our study also shows the need to improve residents' education to prepare them to recognize and address medical errors.

Patient safety in the ambulatory setting. A clinician-based approach

BACKGROUND

Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis.

OBJECTIVES

To determine the feasibility and effectiveness of clinician-based near miss/adverse event voluntary reporting coupled with systems analysis and redesign as a model for continuous quality improvement in the ambulatory setting.

DESIGN

We report the initial 1-year experience of voluntary reporting by clinicians in the ambulatory setting, coupled with root cause analysis and system redesign by a patient safety committee made up of clinicians from the practice.

SETTING

Internal medicine practice site of a large teaching hospital with 25,000 visits per year.

MEASUREMENTS AND MAIN RESULTS

There were 100 reports in the 1-year period, increased from 5 in the previous year. Faculty physicians reported 44% of the events versus 22% by residents, 31% by nurses, and 3% by managers. Eighty-three percent were near misses and 17% were adverse events. Errors involved medication (47%), lab or x-rays (22%), office administration (21%), and communication (10%) processes. Seventy-two interventions were recommended with 75% implemented during the study period.

CONCLUSION

This model of clinician-based voluntary reporting, systems analysis, and redesign was effective in increasing error reporting, particularly among physicians, and in promoting system changes to improve care and prevent errors. This process can be a powerful tool for incorporating error reporting and analysis into the culture of medicine.

Patient safety: the need for an open and fair culture

Intermittent failures of healthcare delivery culminating in patient safety incidents are an international problem. Collecting information on incidents and where necessary analysing causes allows problems to be identified which, when resolved, can prevent future errors and incidents. To support incident reporting, it is vital to have an effective data collecting system and, in addition, an open and fair culture where those who report are supported and not punished. Where this has been introduced, large numbers of incidents are identified and solutions that improve patient safety can be implemented.

Detection of errors by attending physicians on a general medicine service

BACKGROUND

Attending physicians are well positioned to identify medical errors and understand their consequences. The spectrum of errors that can be detected by attending physicians in the course of their usual practice is currently unknown.

OBJECTIVES

To determine the frequency, types, and consequences of errors that can be detected by attending hospitalist physicians in the care of their patients, and to compare the types of errors first discovered by attending hospitalists to those discovered by other providers.

DESIGN

Prospective identification of errors by attending physicians.

SETTING

Two hundred-bed, academic hospital.

PATIENTS

Five hundred twenty-eight patients admitted to the general medicine service from October 2000 to April 2001.

MEASUREMENTS

Errors, both near misses and adverse events, were identified during the course of routine, clinical care by 2 attending hospitalists. Errors first detected by other health care workers were also recorded.

MAIN RESULTS

Of the 528 patients admitted to the hospitalist service, 10.4% experienced at least 1 error: 6.2% a near miss and 4.2% an adverse event. Although differences did not achieve statistical significance, most of the errors first detected by house staff, nurses, and laboratory technicians were adverse events; most of the errors first detected by the attending hospitalists, pharmacists, and consultants were near misses. Drug errors were the most common type of error overall.

CONCLUSIONS

Attending physicians engaged in routine clinical care can detect a range of errors, and differences may exist in the types of errors detected by various health care providers.

Measuring errors and adverse events in health care

In this paper, we identify 8 methods used to measure errors and adverse events in health care and discuss their strengths and weaknesses. We focus on the reliability and validity of each, as well as the ability to detect latent errors (or system errors) versus active errors and adverse events. We propose a general framework to help health care providers, researchers, and administrators choose the most appropriate methods to meet their patient safety measurement goals.

Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project

OBJECTIVE

To evaluate the effectiveness of training and institutionalizing teamwork behaviors, drawn from aviation crew resource management (CRM) programs, on emergency department (ED) staff organized into caregiver teams.

STUDY SETTING

Nine teaching and community hospital EDs.

STUDY DESIGN

A prospective multicenter evaluation using a quasi-experimental, untreated control group design with one pretest and two posttests of the Emergency Team Coordination Course (ETCC). The experimental group, comprised of 684 physicians, nurses, and technicians, received the ETCC and implemented formal teamwork structures and processes. Assessments occurred prior to training, and at intervals of four and eight months after training. Three outcome constructs were evaluated: team behavior, ED performance, and attitudes and opinions. Trained observers rated ED staff team behaviors and made observations of clinical errors, a measure of ED performance. Staff and patients in the EDs completed surveys measuring attitudes and opinions.

DATA COLLECTION

Hospital EDs were the units of analysis for the seven outcome measures. Prior to aggregating data at the hospital level, scale properties of surveys and event-related observations were evaluated at the respondent or case level.

PRINCIPAL FINDINGS

A statistically significant improvement in quality of team behaviors was shown between the experimental and control groups following training (p = .012). Subjective workload was not affected by the intervention (p = .668). The clinical error rate significantly decreased from 30.9 percent to 4.4 percent in the experimental group (p = .039). In the experimental group, the ED staffs' attitudes toward teamwork increased (p = .047) and staff assessments of institutional support showed a significant increase (p = .040).

CONCLUSION

Our findings point to the effectiveness of formal teamwork training for improving team behaviors, reducing errors, and improving staff attitudes among the ETCC-trained hospitals.

An organisation with a memory

Patient safety has been an under-recognised and under-researched concept until recently. It is now high on the healthcare quality agenda in many countries of the world including the UK. The recognition that human error is inevitable in a highly complex and technical field like medicine is a first step in promoting greater awareness of the importance of systems failure in the causation of accidents. Plane crashes are not usually caused by pilot error per se but by an amalgam of technical, environmental, organisational, social and communication factors which predispose to human error or worsen its consequences. In healthcare, the systematic investigation of error in the administration of medication will often reveal similarly complex causation. Experience and research from other sectors, in particular the airline industry, show that the impact of human error can be reduced if the necessary work is put in to detect and then remove weaknesses and vulnerabilties in the system. The NHS is putting in place a comprehensive programme to learn more effectively from adverse events and near misses. This aims to reduce the burden of the estimated 850,000 adverse events which occur in hospitals each year as well as targeting high risk areas such as medication error.

A physician-based voluntary reporting system for adverse events and medical errors

OBJECTIVE

To create a voluntary reporting method for identifying adverse events (AEs) and potential adverse events (PAEs) among medical inpatients.

DESIGN

Medical house officers asked their peers about obstacles to care, injuries or extended hospitalizations, and problems with medications that affected their patients. Two independent reviewers coded event narratives for adverse outcomes, responsible parties, preventability, and process problems. We corroborated house officers' reports with hospital incident reports and conducted a retrospective chart review.

SETTING

The cardiac step-down, oncology, and medical intensive care units of an urban teaching hospital.

INTERVENTION

Structured confidential interviews by postgraduate year-2 and -3 medical residents of interns during work rounds.

MEASUREMENTS AND MAIN RESULTS

Respondents reported 88 events over 3 months. AEs occurred among 5 patients (0.5% of admissions) and PAEs among 48 patients (4.9% of admissions). Delayed diagnoses and treatments figured prominently among PAEs (54%). Clinicians were responsible for the greatest number of incidents (55%), followed by workers in the laboratory (11%), radiology (15%), and pharmacy (3%). Respondents identified a variety of problematic processes of care, including problems with diagnosis (16%), therapy (26%), and failure to provide clinical and support services (29%). We corroborated 84% of reported events in the medical record. Participants found voluntary peer reporting of medical errors unobtrusive and agreed that it could be implemented on a regular basis.

CONCLUSIONS

A physician-based voluntary reporting system for medical errors is feasible and acceptable to front-line clinicians.

Confidential clinician-reported surveillance of adverse events among medical inpatients

BACKGROUND

Although iatrogenic injury poses a significant risk to hospitalized patients, detection of adverse events (AEs) is costly and difficult.

METHODS

The authors developed a confidential reporting method for detecting AEs on a medicine unit of a teaching hospital. Adverse events were defined as patient injuries. Potential adverse events (PAEs) represented errors that could have, but did not result in harm. Investigators interviewed house officers during morning rounds and by e-mail, asking them to identify obstacles to high quality care and iatrogenic injuries. They compared house officer reports with hospital incident reports and patients' medical records. A multivariate regression model identified correlates of reporting.

RESULTS

One hundred ten events occurred, affecting 84 patients. Queries by e-mail (incidence rate ratio [IRR] = 0.16; 95% confidence interval [95% CI], 0.05 to 0.49) and on days when house officers rotated to a new service (IRR = 0.12; 95% CI, 0.02 to 0.91) resulted in fewer reports. The most commonly reported process of care problems were inadequate evaluation of the patient (16.4%), failure to monitor or follow up (12.7%), and failure of the laboratory to perform a test (12.7%). Respondents identified 29 (26. 4%) AEs, 52 (47.3%) PAEs, and 29 (26.4%) other house officer-identified quality problems. An AE occurred in 2.6% of admissions. The hospital incident reporting system detected only one house officer-reported event. Chart review corroborated 72.9% of events.

CONCLUSIONS

House officers detect many AEs among inpatients. Confidential peer interviews of front-line providers is a promising method for identifying medical errors and substandard quality.