Incidence Of Preventable Adverse Events Research Articles

Incidence of preventable adverse events in the hospitalization services of a Clinic from Sincelejo city (Colombia)

En la actualidad, un parámetro importante de satisfacción del cliente en las IPS es la seguridad. Anualmente se reportan 134 millones de eventos adversos (EA) debido a la atención insegura, lo que ocasiona un gran número de muertes y aumento en los costos de la atención. Objetivo: Estimar la incidencia de eventos adversos prevenibles en los servicios de hospitalización de una clínica de la ciudad de Sincelejo (Colombia) en 2021. Métodos: Estudio de incidencia en 360 historias clínicas de pacientes ingresados en los servicios de hospitalización durante junio de 2021 en una clínica de la ciudad de Sincelejo, Colombia. Se aplicó la Guía de Cribado para búsqueda de indicios de Eventos Adversos (EA); a los pacientes con cribado positivo se les aplicó el módulo A de identificación de EA, contenido en el formulario modular para revisión retrospectiva de casos. Se realizó análisis descriptivo y evaluación de asociaciones. Resultados: Se obtuvieron 54 indicios de EA, la incidencia fue de 6,11 % de EA prevenibles, la mayoría de estos moderados 54,5 % y severos 31,8 %. La especialidad con mayor incidencia fue Medicina Interna (45,5 %), seguido de las especialidades quirúrgicas 36,4 %; Cabe resaltar que el 54,5 % de los eventos estuvo relacionado con factores de riesgo extrínsecos. Conclusiones: Este es el primer estudio realizado en la institución y permitió identificar la incidencia de eventos adversos prevenibles a través de la Guía de Cribado para la revisión retrospectiva de las historias clínicas, que mostró ser una herramienta útil para este fin.

Incidence of adverse events, preventability and mortality in gynaecological hospital admissions: A systematic review and meta-analysis.

Adverse events (AEs) are unintended consequences of healthcare management that result in temporary or permanent disability, death or prolonged hospital stay. The incidence of AEs has been reported to be higher in surgical specialties compared to medical specialties but information on the incidence of AEs in gynaecology is sparse. To collect evidence on the incidence, preventability and mortality of AEs in gynaecological hospital admissions by conducting a systematic review and meta-analysis. A systematic search of the PubMed, EMBASE, and CINAHL electronic medical databases was performed. Identified articles were screened and a full-text review was conducted by two independent reviewers. Of the 49 studies assessed for eligibility, three studies were included in this systematic review. Meta-analysis showed that the incidence of AEs in gynaecological hospital admissions was 10.8% (95% CI 9.4-12.1%), preventability was 52.5% (95% CI 47.3-57.7%) and mortality was 1.2% (95% CI 0-2.5%). Evidence on AEs in gynaecological hospital admissions is limited. Available evidence suggests that approximately one in ten gynaecological inpatients suffer at least one AE and half of AEs are considered preventable. Further research is needed to determine strategies regarding how the incidence of preventable AEs can be reduced.

Adverse events related to hospital care: a retrospective medical records review in a Swiss hospital.

Retrospective records reviews carried out in several countries have shown substantial rates of adverse events (AE) among hospitalized patients, preventable in half the cases. As no such data have been recorded in Switzerland, we estimated the incidence of AE in one acute care hospital as a basis for a safety improvement program. A two steps retrospective records review (screening criteria and full review of positively screened records). A medium size community hospital. A stratified sample of 400 surgical and 600 medical hospitalizations whose records fulfilled a set of information quality criteria. Not applicable. Adverse events, preventable adverse events and extent of resulting harm. The proportion of hospitalizations with at least one AE was 12.3% (95% CI: 10.4-14.1) whereas the overall hospital incidence rate was 14.1% (95% CI: 12.0-16.2). Nearly half of AE were judged preventable, corresponding to one or more preventable AE in 6.4% of hospitalizations (95% CI: 5.0-7.8). Sixty percent of AE resulted in no or minor impairment at discharge whereas 23% resulted in severe disability. AE were twice more frequent in surgical patients, and preventable AE resulted more often in severe impairment than unpreventable AE. No death was attributed to an AE. The proportion of stays with an AE increased with age and length of stay. The incidence of preventable AE in patients hospitalized in one Swiss hospital is comparable to previously reported rates. Further, patient safety improvement is needed, especially among older patients, and for surgical procedures.

Ethnic minority patients not at increased risk of adverse events during hospitalisation in urban hospitals in the Netherlands: results of a prospective observational study

ObjectivesWe analysed potential differences in incidence, type, nature, impact and preventability of adverse events (AEs) during hospitalisation between ethnic Dutch and ethnic minority patients, and the role of patient-related determinants....

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study

Limited data are available on adverse events among children admitted to hospital. The Canadian Paediatric Adverse Events Study was done to describe the epidemiology of adverse events among children in hospital in Canada. We performed a 2-stage medical record review at 8 academic pediatric centres and 14 community hospitals in Canada. We reviewed charts from patients admitted from April 2008 through March 2009, evenly distributed across 4 age groups (0 to 28 d; 29 to 365 d; > 1 to 5 yr and > 5 to 18 yr). In stage 1, nurses and health records personnel who had received training in the use of the Canadian Paediatric Trigger Tool reviewed medical records to detect triggers for possible adverse events. In stage 2, physicians reviewed the charts identified as having triggers and described the adverse events. A total of 3669 children were admitted to hospital during the study period. The weighted rate of adverse events was 9.2%. Adverse events were more frequent in academic pediatric centres than in community hospitals (adjusted odds ratio [OR] 2.98, 95% confidence interval [CI] 1.65-5.39). The incidence of preventable adverse events was not significantly different between types of hospital, but nonpreventable adverse events were more common in academic pediatric centres (adjusted OR 4.39, 95% CI 2.08-9.27). Surgical events predominated overall and occurred more frequently in academic pediatric centres than in community hospitals (37.2% v. 21.5%, relative risk [RR] 1.7, 95% CI 1.0-3.1), whereas events associated with diagnostic errors were significantly less frequent (11.1% v. 23.1%, RR 0.5, 95% CI 0.2-0.9). More children have adverse events in academic pediatric centres than in community hospitals; however, adverse events in the former are less likely to be preventable. There are many opportunities to reduce harm affecting children in hospital in Canada, particularly related to surgery, intensive care and diagnostic error.

Physical Environment Design for Improving Patient Safety

The need to improve patient safety is well recognized (Leape et al., 2009; Pronovost, Berenholtz, & Morlock, 2011; Wachter, 2010). How to accomplish this and where to focus efforts, however, is less clear. In any health-related work system, there are five components that affect care: people (care providers, patients), tasks, technologies/ tools, organization, and the physical environment (Carayon et al., 2006). Although each of these components has a significant impact on work processes and outcomes, few-if any-patient safety improvement initiatives or research efforts have focused on the physical design of environments. Yet everything we do in healthcare is, to some extent, defined and affected by the physical environmentThe physical environment can influence patient safety directly or indirectly. For example, when an environment is designed to reduce the transmission of airborne and contact infectious agents, hospitalacquired infections plummet (Ulrich et al., 2008). In addition, illumination levels have been linked to pharmacists' medication dispensing error rates (Buchanan, Barker, Gibson, Jiang, & Pearson, 1991). The physical environment can indirectly affect patient safety by influencing other components of a care system. For example, the physical design of a setting could hinder communication and teamwork among care providers (Becker, 2007; Smith, Schoenbeck, & Clayton, 2009), two factors critical to providing safe care (Neily et al., 2010; Sutcliffe, Lewton, & Rosenthal, 2004). Nonetheless, the norm is to haphazardly redesign healthcare spaces rather than systematically and comprehensively consider the implications of these design decisions on patient safety and quality of care. In the remainder of this editorial, we discuss multiple reasons for such limited forethought and propose solutions.Limited EvidenceThere is little evidence describing how to design safer patient care environments. A major reason for this paucity of evidence is lack of funding to support research in this area. Some funding opportunities focus on other factors that have an impact on safety, such as organization/teamwork, tasks, tools, and provider performance. Very few of these, if any at all, focus on designing a safer physical environment. More research is needed to discover how to (re)design physical environments to enhance processes (e.g., to foster easier compliance with guidelines and safer intra-hospital patient transport) and reduce the incidence of preventable adverse events (e.g., the design of patient rooms to reduce the number of falls).Insufficiently Rigorous Methods and ToolsAmong the handful of studies published on environmental design, very few have used rigorous and scientifically sound methodologies. Furthermore, healthcare organizations desperately need practical yet rigorous methods to plan, implement, and evaluate new or redesigned physical space projects. Organizations should conduct usability studies that test physical design alternatives to see what works best before investing millions of dollars in a design project. Some practical tools and methods that organizations can use to test and choose appropriate designs include observations in the real world, link analysis, task analysis, simulations, and iterative mock-ups.A Non-Interdisciplinary ApproachThe majority of physical design studies are done within one discipline (such as architecture). Although important, this reflects only one viewpoint. Patient safety research is interdisciplinary in nature. Other professionals such as human factors engineers, psychologists, anthropologists, health services researchers, operations researchers, organizational managers, clinicians, and architects have valuable input when designing physical environments for safer care.Learning From Mistakes and SuccessesPhysical (re)design efforts are typically expensive and hard to modify or fix in the short term. Thus, it is imperative that healthcare organizations collaborate and learn from each others' collective successes and failures during physical environment design efforts. …

Medical emergency teams: a role for expanding intensive care?

A high incidence of preventable adverse events and deaths in hospitals has triggered initiatives to improve the quality of care of acutely ill in-hospital patients. System changes involving the introduction of medical emergency teams, outreach services or rapid response teams are an integral part of these initiatives. The rationale for implementing a designated team is that early recognition and rapid institution of adequate therapy for the deteriorating patient can improve outcome. The concept of bringing intensive care expertise to any acutely ill patient irrespective of location within the hospital is envisioned as "critical care without walls". Studies were identified by a PubMed search and cited references in key publications provided additional material including www-resources. More than 80 studies were identified and selected for review, however, no formal search strategy for a systematic review or meta-analysis was attempted. Only studies published in English were considered. Several non-randomized, before-and-after cohort studies demonstrate that implementation of medical emergency teams and equivalents can reduce the incidence of cardiac arrests, unexpected deaths, and unplanned intensive care admissions. However, one recent randomized, controlled trial of medical emergency teams failed to demonstrate any differences in outcomes. Several key operational issues need to be addressed before introducing medical emergency response teams based on current evidence. These issues include differences in healthcare systems and performance, patient case-mix, resources available, composition of the teams and calling criteria, and strategies for education, audit and governance.

Patient safety problems in adolescent medical care

Purpose This study estimates the annual incidence and describes the nature, types, and contributing factors involved in patient safety problems in adolescent medical care. Methods This study uses data from the population-based Colorado and Utah Medical Practice Study to describe the incidence of hospital-based adverse events and preventable adverse events in adolescents and “critical incidence analysis” data reported by pediatric clinicians to elucidate the nature, types, and contributing factors in adolescent patient safety problems. Results The incidence of adverse events in adolescents in the Colorado and Utah Medical Practice Study was 2.74 (CI 95% = 2.62–2.86), significantly higher than all other age groups of children. The incidence of preventable adverse events in adolescents was 0.95 (CI 95% = 0.65–1.25), significantly higher than that of children 1–12 years old, but not significantly different than infants. Diagnostic events were most common, followed by medication events. Services associated with the highest frequency of events were pharmacy and Family Practice. In the critical incident analysis, adolescent-specific factors contributed to 54.8% of the described patient safety problems. Discomfort with adolescents, a factor not described for other age groups of children, contributed to 17% of the adolescent patient safety problems. Conclusions Adolescents experience relatively high rates of patient safety problems compared with other age groups of children. Adolescents represent a defined population with a patient safety risk profile that differs from adults and younger children. The substantial contribution of adolescent-specific factors suggests that patient safety improvements, to be effective, should address adolescent-specific risks.

Preventable Adverse Events in Infants Hospitalized With Bronchiolitis

To determine the incidence of preventable adverse events (AEs) and near misses (NMs) among infants hospitalized for bronchiolitis at a pediatric tertiary care hospital and the impact of these errors on hospital length of stay (LOS). We studied 143 infants with bronchiolitis, ages 0 to 12 months, admitted from December 2002 to April 2003. Using prospective chart review and staff reports, we captured medical errors and AEs. Each event was classified as a (1) preventable AE, (2) nonpreventable AE, (3) intercepted NM, (4) nonintercepted NM, or (5) error with little or no potential for harm. Of 143 patients, 15 (10%) suffered an AE or NM. The incidence of preventable AEs was 10 per 100 admissions. We found a higher incidence of preventable AEs and NMs among critically ill patients (CIPs) compared with non-CIPs (68 vs 5 per 100 admissions, respectively), making the absolute risk of an AE or NM 14 times more likely in CIPs. Mean LOS was significantly longer for CIPs with at least 1 AE (9.1 +/- 8.8 days) than for CIPs without AEs (2.9 +/- 1.5 days). Mean LOS was not significantly different between non-CIPs who did (3.8 +/- 2.6 days) and did not (4.2 +/- 5.0 days) experience an AE. Preventable AEs occur frequently among patients admitted for bronchiolitis, especially those who are critically ill. CIPs who suffer AEs during their hospitalization have longer hospital LOSs. Future studies should investigate error-prevention strategies with a focus on those patients with severe disease.

Result-oriented remuneration for hospital inpatient care

Fee-for-benefit means the adjustment of the reimbursement at the quality of care. Both a bonus and a penalty are possible. It is suggested to measure innovative therapies with outcome parameters and give a bonus as an incentive for quality improvements. Standard therapies should be measured with process parameters and be sanctioned with a penalty when the standards are missed. To determine the extend of the bonus and the penalty, the variable costs of a hospital could be used as a reference. Therefore a penalty should not exceed approximately 25 % of the reimbursement. The costs for the introduction and administration of the fee-for-benefit reimbursement must be seen in the context of the necessary improvement of quality insurance in per-case reimbursement with DRG (Diagnosis-Related Groups) in Germany. Related to the incidence of preventable adverse events and the additional costs of poor-quality outcome evaluated from studies fee-for-benefit will be cost-effective by avoiding every sixth adverse event. German legislation allows fee-for-benefit only in small model projects or local integrated networks. It is recommended to allow an optional opening of negotiations between hospitals and sickness funds for fee-for-benefit elements. A pilot study should evaluate the incidence and cost of preventable adverse events in Germany.

Incidence and types of preventable adverse events in elderly patients: population based review of medical records

Objectives: To determine the incidence and types of preventable adverse events in elderly patients.Design: Review of random sample of medical records in two stage process by nurses and physicians to...