Descriptive Epidemiology of Safety Events at an Academic Medical Center.

Alexandre R Marra,Mohammed Alzunitan,Michael B Edmond,Abdullah Algwizani,Theresa M H Brennan

doi:10.3390/ijerph17010353

Abstract

Background: Adverse safety events in healthcare are of great concern, and despite an increasing focus on the prevention of error and harm mitigation, the epidemiology of safety events remains incomplete. Methods: We performed an analysis of all reported safety events in an academic medical center using a voluntary incident reporting surveillance system for patient safety. Safety events were classified as: serious (reached the patient and resulted in moderate to severe harm or death); precursor (reached the patient and resulted in minimal or no detectable harm); and near miss (did not reach the patient). Results: During a three-year period, there were 31,817 events reported. Most of the safety events were precursor safety events (reached the patient and resulted in minimal harm or no detectable harm), corresponding to 77.3%. Near misses accounted for 10.8%, and unsafe conditions for 11.8%. The number of reported serious safety events was low, accounting for only 0.1% of all safety events. Conclusions: The reports analysis of these events should lead to a better understanding of risks in patient care and ways to mitigate it.

Highlights

Many healthcare organizations are engaged in improving their safety culture and transitioning to high reliability [1–3]
Near misses accounted for 10.8%, unsafe conditions for 11.8%, and serious safety events accounted for 0.1%
Evaluating the harm score categories by each event type (Table 4), we found that medication errors accounted for nearly one-half of near misses (40.4%)

Summary

Introduction

Many healthcare organizations are engaged in improving their safety culture and transitioning to high reliability [1–3]. Reporting safety events improves the safety culture in hospitals [4,5], and by analyzing reported safety events, severe patient harm, including deaths, may be prevented [4]. Reporting and analysis of near miss events are valuable as these events represent the potential for future harm [3]. The proportion of serious adverse events, small (1 per 1000 admissions) cannot be negligible [7] If this rate is applied to 34.7 million inpatients in the United States (US) [8], an estimated 35,000 patients per year could be seriously or permanently injured or could die during hospitalization due to an adverse event [7]. Safety events were classified as: serious (reached the patient and resulted in moderate to severe harm or death); precursor (reached the patient and resulted in minimal or no detectable harm); and near miss (did not reach the patient). The number of reported serious safety events was low, accounting for only

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