Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital

Abstract

Objectives: To estimate the extent, nature and consequences of adverse events in a large National Health Service (NHS) hospital, and to evaluate the reliability of a two-stage casenote review method in identifying adverse events. Design: A two-stage structured retrospective patient casenote review. Setting: A large NHS hospital in England. Population: A random sample of 1006 hospital admissions between January and May 2004: surgery (n = 311), general medicine (n = 251), elderly (n = 184), orthopaedics (n = 131), urology (n = 61) and three other specialties (n = 68). Main outcome measures: Proportion of admissions with adverse events, the proportion of preventable adverse events, and the types and consequences of adverse events. Results: 8.7% (n = 87) of the 1006 admissions had at least one adverse event (95% CI 7.0% to 10.4%), of which 31% (n = 27) were preventable. 15% of adverse events led to impairment or disability which lasted more than 6 months and another 10% contributed to patient death. Adverse events led to a mean increased length of stay of 8 days (95% CI 6.5 to 9). The sensitivity of the screening criteria in identifying adverse events was 92% (95% CI 87% to 96%) and the specificity was 62% (95% CI 53% to 71%). Inter-rater reliability for determination of adverse events was good (k = 0.64), but for the assessment of preventability it was only moderate (k = 0.44). Conclusion: This study confirms that adverse events are common, serious and potentially preventable source of harm to patients in NHS hospitals. The accuracy and reliability of a structured two-stage casenote review in identifying adverse events in the UK was confirmed. S tudies across the world have shown that between 3% and 17% of hospital admissions result in an adverse event (defined as any unintended event caused at least partly by healthcare and which resulted in harm), and that between 28 and 75 percent of them are preventable.

Litigation related to anaesthesia: an analysis of claims against the NHS in England 1995–2007

“…The data should not be interpreted as indicating the frequency of clinical complications, as only a small proportion of all clinical incidents or patient injuries lead to litigation [1][2][3][4]. We also lack denominator data meaning that high representation in this dataset might be due to high denominator rates or a disproportionate increase in claims for some incidents.…”

“…In 1991 Brennan [1] in America reported avoidable patient harm in 4% of hospitalisations, while in Australia in 1995 Wilson [2] reported adverse events in 17%. In the UK, in 2001, Vincent [3] reported iatrogenic harm in 11% of hospital admissions and in 2007 Sari [4] reported a 9% rate. Up to half of all these incidents are deemed 'avoidable' and many are associated with substandard or negligent care: around 1 in 10 contributes to patient death [1][2][3][4].…”

“…In the UK, in 2001, Vincent [3] reported iatrogenic harm in 11% of hospital admissions and in 2007 Sari [4] reported a 9% rate. Up to half of all these incidents are deemed 'avoidable' and many are associated with substandard or negligent care: around 1 in 10 contributes to patient death [1][2][3][4]. Patient harm may lead to medico-legal claims against doctors and organisations.…”

Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research

“…Since, further studies in the USA as well as in other countries, including the UK, have found similar and often slightly higher figures. [7][8][9][10][11][12] There is now available a wealth of research from different medical specialties and different countries that indicates that health care is a high-risk domain where patients may be harmed, for example in surgery 13,14 or medicines management and prescribing. 15,16 In addition to causing needless harm and suffering to patients, poor-quality health-care provision has significant financial implications for the health systems.…”

Incidentes de segurança ocorridos com pacientes durante o cuidado de enfermagem

“…13,14 Isto é importante visto que o reconhecimento da ocorrência pelos profissionais de saúde é a base para o estabelecimento de uma cultura de segurança organizacional, com adoção de medidas de prevenção a eventos adversos. 15,16 Impulsionadas pela relevância da temática, um grupo de enfermeiras de um hospital universitário do sul do Brasil, atualmente acreditado pela JCI, percebeu a necessidade de identificar as ocorrências de incidentes de segurança na instituição e de analisá-las, a fim de implementar medidas de prevenção e favorecer a segurança dos pacientes. Somado a isto, o processo de acreditação pela JCI pelo qual passava o hospital reforçou esta necessidade, visto que o cuidado aos pacientes deve estar focado na realização de procedimentos de forma correta e com resultados efetivos, prevenindo riscos e reduzindo ou eliminando erros durante o processo de trabalho.…”