A Comprehensive Overview of Medical Error in Hospitals Using Incident-Reporting Systems, Patient Complaints and Chart Review of Inpatient Deaths

Background Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions. Methods The aim of this paper was to provide a more comprehensive overview of medical error in hospitals using a combination of different information sources. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. The main outcome measures were distribution of incidents over the thirteen categories of the ICPS classifier “Incident type”, described as odds ratios (OR) and proportional similarity indices (PSI). Results A total of 1012 incidents resulted in 1282 classified items. Large differences between data from IRS and patient complaints (PSI = 0.32) and from IRS and retrospective chart review (PSI = 0.31) were mainly attributable to behaviour (OR = 6.08), clinical administration (OR = 5.14), clinical process (OR = 6.73) and resources (OR = 2.06). Conclusions IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety.

[1]  E. Berner,et al.  Overconfidence as a cause of diagnostic error in medicine. , 2008, The American journal of medicine.

[2]  J M Ansermino,et al.  Time to listen: a review of methods to solicit patient reports of adverse events , 2010, Quality and Safety in Health Care.

[3]  M. Farahbakhsh,et al.  Study of patient complaints reported over 30 months at a large heart centre in Tehran , 2010, Quality and Safety in Health Care.

[4]  P. Barach,et al.  Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems , 2000, BMJ : British Medical Journal.

[5]  H. Stelfox,et al.  Content analysis of patient complaints. , 2008, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[6]  Beth M Averbeck,et al.  Can patient safety be measured by surveys of patient experiences? , 2008, Joint Commission journal on quality and patient safety.

[7]  Hardeep Singh,et al.  Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. , 2007, Archives of internal medicine.

[8]  J. Pichert,et al.  Patient complaints and malpractice risk. , 2002, JAMA.

[9]  J. Weissman,et al.  Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not? , 2008, Annals of Internal Medicine.

[10]  T. Ba,et al.  Patient reports of undesirable events during hospitalization , 2005, Journal of General Internal Medicine.

[11]  Jacob Cohen.  A Coefficient of Agreement for Nominal Scales , 1960 .

[12]  Pierre Lewalle,et al.  Towards an International Classification for Patient Safety: the conceptual framework , 2009, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[13]  R. Thomson,et al.  Towards an International Classification for Patient Safety: key concepts and terms , 2009, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[14]  Laura A. Petersen,et al.  Measuring errors and adverse events in health care , 2003, Journal of general internal medicine.

[15]  Philippe Michel,et al.  Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals , 2004, BMJ : British Medical Journal.

[16]  S. Pauker,et al.  Voluntary electronic reporting of medical errors and adverse events , 2006, Journal of General Internal Medicine.

[17]  Carol A. Keohane,et al.  Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant. , 2010, Joint Commission journal on quality and patient safety.

[18]  Christel Daniel-Le Bozec,et al.  Is the "International Classification for Patient Safety" a Classification? , 2009, MIE.

[19]  T. Brennan,et al.  INCIDENCE OF ADVERSE EVENTS AND NEGLIGENCE IN HOSPITALIZED PATIENTS , 2008 .

[20]  J. Reason.  Understanding adverse events: human factors. , 1995, Quality in health care : QHC.

[21]  Trevor A Sheldon,et al.  Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review , 2006, BMJ : British Medical Journal.

[22]  P. Pronovost,et al.  Diagnostic errors--the next frontier for patient safety. , 2009, JAMA.

[23]  M. Välimäki,et al.  Patient complaints in Finland 2000–2004: a retrospective register study , 2008, Journal of Medical Ethics.

[24]  T. Brennan,et al.  Incidence and types of adverse events and negligent care in Utah and Colorado. , 2000, Medical care.

[25]  G. Bartlett,et al.  Can We Use Incident Reports to Detect Hospital Adverse Events? , 2008 .

[26]  Brian J Smith,et al.  Consumer perceptions of safety in hospitals , 2006, BMC public health.

[27]  Roger B. Davis,et al.  What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents , 2005, Journal of General Internal Medicine.

[28]  Cordula Wagner,et al.  Design of a retrospective patient record study on the occurrence of adverse events among patients in Dutch hospitals , 2007, BMC Health Services Research.

[29]  Catherine Yoon,et al.  Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. , 2007, Annals of emergency medicine.

[30]  N. Franklin,et al.  Diagnostic error in internal medicine. , 2005, Archives of internal medicine.

[31]  Tannaz Moin,et al.  Consequences of inadequate sign-out for patient care. , 2008, Archives of internal medicine.

[32]  J. Tibballs,et al.  Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit , 2010, Quality and Safety in Health Care.

[33]  Stephen G. Pauker,et al.  Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals. , 2006 .

[34]  Pierre Lewalle,et al.  Towards an International Classification for Patient Safety: a Delphi survey , 2009, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[35]  R. Holloway,et al.  Electronic reporting to improve patient safety , 2004, Quality and Safety in Health Care.

[36]  P. Maurette,et al.  [To err is human: building a safer health system]. , 2002, Annales francaises d'anesthesie et de reanimation.

[37]  A. Wall,et al.  Book ReviewTo Err is Human: building a safer health system Kohn L T Corrigan J M Donaldson M S Washington DC USA: Institute of Medicine/National Academy Press ISBN 0 309 06837 1 $34.95 , 2000 .

[38]  C. Lessing,et al.  Impact of sample size on variation of adverse events and preventable adverse events: systematic review on epidemiology and contributing factors , 2010, Quality and Safety in Health Care.

[39]  Svante Janson,et al.  Measures of similarity between distributions , 1986 .

[40]  Katherine J. Jones,et al.  Translating research into practice: voluntary reporting of medication errors in critical access hospitals. , 2004, The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association.

[41]  T. Brennan,et al.  Incidence of adverse events and negligence in hospitalized patients. , 1991, The New England journal of medicine.

[42]  C Wagner,et al.  Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study , 2002, Quality & Safety in Health Care.

[43]  R. Thomson,et al.  Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System , 2009, Quality & Safety in Health Care.

[44]  Charles Vincent,et al.  Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place , 2007, Quality and Safety in Health Care.

[45]  B. Guglielmo,et al.  Systematic review of medication safety assessment methods. , 2011, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.