Impact and preventability of adverse events in Spanish public hospitals: results of the Spanish National Study of Adverse Events (ENEAS)

Andrés, Jesús María Aranaz; Remón, Carlos Aibar; Vitaller-Burillo, Julián; Requena-Puche, Juana; Terol-García, Enrique; Kelley, Ed; Castro, M.T. Gea-Velázquez de

doi:10.1093/intqhc/mzp047

Cited by 116 publications

(114 citation statements)

References 21 publications

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“…Numerous studies in different countries have been conducted using this approach in the last years. These studies revealed adverse event rates of 5-15% of all acute care hospital admissions [4][5][6][7][8] . Approximately 50% of events were deemed preventable [5] .…”

Section: Health Care As a Risk: The Magnitude Of The Safety Problemmentioning

confidence: 99%

Patient Safety: What Is It All about?

Schwappach

2015

Contributions to Nephrology

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Patient safety is a major concern in health care systems worldwide. Patients with serious conditions, multimorbidity, and with intense and fragmented health care utilization, like end-stage renal disease (ESRD) patients, are at increased risk for suffering adverse events. In this chapter, the fundamental terms and concepts of patient safety are introduced. Essential epidemiological data relating to the frequency of adverse events and medical errors are provided. The chapter reports important safety threats for ESRD patients and describes examples of key innovations which contribute to patient safety. Recommendations and risk reduction strategies to improve care of ESRD patients are presented.

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Section: Health Care As a Risk: The Magnitude Of The Safety Problemmentioning

confidence: 99%

Patient Safety: What Is It All about?

Schwappach

2015

Contributions to Nephrology

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“…31 In stage 2, using the modular review form 2 (MRF2), doctors trained in the use of a standard set of questions analyse positively screened records in detail to determine whether or not they contain evidence of an AE. The basic method has been followed in all the major epidemiological studies, 14,16,[32][33][34][35][36][37][38][39] although there have been modifications to the review form and data capture methods. 30 Previous work in a UK setting, 16,24 assessing the sensitivity of the two-stage review process, reported a sensitivity of 92% and a specificity of 62%.…”

Section: Retrospective Case Note Reviewmentioning

confidence: 99%

“…14,16,[32][33][34][35][36][37][38][39] The study groups all made sequential changes to the original form by adding or subtracting questions, but maintaining the basic format. Charles Vincent and his group made revisions to the review forms, providing a stronger focus on causation and a more tightly structured format after using the tool in a UK setting; this iteration, known as the MRF2, 30,31 is the one used in the study and found in Appendix 1.…”

Section: The Review Toolsmentioning

confidence: 99%

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Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study

Mayor

Baines

Vincent

et al. 2017

Health Serv Deliv Res

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Background, objectives and settingDespite global activity over the past 15 years to improve patient safety, the measurement of adverse events (AEs) remains challenging.ObjectivesWe aimed to obtain definitive longitudinal data on harm across NHS Wales and to compare the performance of the Global Trigger Tool (GTT) with the two-stage retrospective review process, using our findings to consolidate an approach to the ongoing surveillance of harm in Wales.Data sourcesEleven of the 13 major Welsh NHS hospitals.Review methodsThe two-stage retrospective review methodology was used to quantify harm across NHS Wales. In total, 4536 inpatient episodes were screened for AEs by research nurses. Records that were highly suggestive of AEs were further assessed by physicians. NHS-led teams undertook GTT reviews on the same case notes.ResultsAt least one AE was determined in 10.3% of episodes of care [95% confidence interval (CI) 9.4% to 11.2%] and 51.5% were preventable (95% CI 46.9% to 56.1%). The percentage of patients identified with AEs using the GTT methodology was lower, at 9.0% (95% CI 8.82% to 9.18%). Differences in AEs were evident across study sites. Methods were developed to profile the risk of AEs in individual organisations by producing signatures of harm for each NHS site. Analysis indicated that neither the GTT nor the two-stage process was a candidate tool for routine surveillance, and a hybrid one-stage tool (Harm2), based on phase 1 findings, was developed for ongoing AE monitoring. Using the Harm2 tool, AEs were identified in 371 out of 3352 randomly selected discharge reviews (11.3%, 95% CI 10.2% to 12.4%), and 59.6% (95% CI 55.3 to 63.9) of these were preventable. In a cohort of randomly selected deceased patient reviews, at least one AE was determined in 315 out of 1018 admissions (30.1%, 95% CI 28.1% to 33.8%), and 61.7% (95% CI 57.5% to 65.9%) of these were preventable. Factors associated with AEs in the randomly selected discharge reviews included having peripheral vascular disease [odds ratio (OR) 2.52], hemiplegia (OR 2.27) or dementia (OR 2.27). No association with chronic disease was identified in the deceased episodes of care.LimitationsThe dependence on our health service partners in identifying notes to be reviewed, along with the small sample examined each month, limits the generalisability of these findings and rates were not standardised for hospital and size and level of services provided. We cannot rule out the possibility that the rates we report may be underestimated.ConclusionThe extent of harm detected across NHS Wales using both the two-stage retrospective review process and the new Harm2 tool conforms to the findings in the literature, but this is the first longitudinal study using these methods. With training and using a structured review process, non-physician reviewers can undertake case note review efficiently and effectively, and the rates of AEs and of the preventability and the breakdown of problems in care conform to those reported in studies in which physicians undertake these classifications. Whether the patient died or was discharged alive significantly influences the rate and composition of AEs. The Harm2 tool performed with moderate reliability in the determination of AEs.Future workFuture large-scale studies should attempt to specify types of AEs, such as hospital-acquired infections and surgical complications, to enable the surveillance of the specific types of harm as well as the overall level of AEs. In the longer term, we need to automate harm surveillance and set measures of harm alongside measures of the beneficial effects of health care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…Most adverse event reporting systems (with a few exceptions) are designed to be used by health care providers rather than consumers. 2 See Aranaz-Andrés, Aibar-Remó, Vitaller-Burillo, et al, 2009;Baker, Norton, Flintoft, et al, 2004;Brennan, Leape, Laird, Herbert, Localio, et al,, 1991;Michel, Quenon, Djihoud, Tricaud-Vialle, de Sarasqueta, 2007;Thomas, Studdert, Burstin, et al, 2000;Vincent, Neale, and Woloshynowych, 2001;Wilson, Runciman, Gibberd, Harrison, and Hamilton, 1996. 3 See The Health Foundation, undated; World Health Organization, undated; Institute for Healthcare Improvement, 2001.…”

Section: Introductionmentioning

confidence: 99%

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events

Schneider¹,

Ridgely²,

Quigley³

et al. 2016

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Impact and preventability of adverse events in Spanish public hospitals: results of the Spanish National Study of Adverse Events (ENEAS)

Abstract: In Spanish hospitals, AEs associated with health care cause distress, disability, death, lengthen hospital stay and cause increased consumption of health-care resources. A relatively high percentage of AEs in Spain may be preventable with improvements in medical care.

Cited by 116 publications

References 21 publications

Patient Safety: What Is It All about?

Patient Safety: What Is It All about?

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events

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