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QJM. 2015 Apr;108(4):273-7. doi: 10.1093/qjmed/hcu145. Epub 2014 Jul 29.

Adverse events in healthcare: learning from mistakes.

Author information

1
From the Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, St Stephens Green, Dublin 2, Ireland, Division of Population Health Sciences, Royal College of Surgeons in Ireland, St Stephens Green, Dublin 2, Ireland, Health Services Executive, Dr Steeven's Hospital, Dublin 8, Ireland, Whitaker Institute, Department of General Practice, National University of Ireland, Galway, Ireland and Royal College of Physicians of Ireland, Frederick House, 19 South Frederick St, Dublin 2, Ireland natasharafter@rcsi.ie.
2
From the Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, St Stephens Green, Dublin 2, Ireland, Division of Population Health Sciences, Royal College of Surgeons in Ireland, St Stephens Green, Dublin 2, Ireland, Health Services Executive, Dr Steeven's Hospital, Dublin 8, Ireland, Whitaker Institute, Department of General Practice, National University of Ireland, Galway, Ireland and Royal College of Physicians of Ireland, Frederick House, 19 South Frederick St, Dublin 2, Ireland.

Abstract

Large national reviews of patient charts estimate that approximately 10% of hospital admissions are associated with an adverse event (defined as an injury resulting in prolonged hospitalization, disability or death, caused by healthcare management). Apart from having a significant impact on patient morbidity and mortality, adverse events also result in increased healthcare costs due to longer hospital stays. Furthermore, a substantial proportion of adverse events are preventable. Through identifying the nature and rate of adverse events, initiatives to improve care can be developed. A variety of methods exist to gather adverse event data both retrospectively and prospectively but these do not necessarily capture the same events and there is variability in the definition of an adverse event. For example, hospital incident reporting collects only a very small fraction of the adverse events found in retrospective chart reviews. Until there are systematic methods to identify adverse events, progress in patient safety cannot be reliably measured. This review aims to discuss the need for a safety culture that can learn from adverse events, describe ways to measure adverse events, and comment on why current adverse event monitoring is unable to demonstrate trends in patient safety.

PMID:
25078411
DOI:
10.1093/qjmed/hcu145
[Indexed for MEDLINE]

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