Adverse events in acute care: An integrative literature review

Research in Nursing and Health

Volumn 26, Issue 5, 2003, Pages 398-408

  Kellogg, Victoria A ^a,c   Havens, Donna Sullivan ^b  

^a PENNSYLVANIA STATE UNIVERSITY   (United States)

^b UNIVERSITY OF NORTH CAROLINA   (United States)

^c NONE   (United States)

Author keywords

Adverse events; Health services; Integrative literature review; Medical; Nursing

Indexed keywords

HEALTH CARE; HEALTH CARE QUALITY; HEALTH SERVICE; HUMAN; NURSING; REVIEW; SAMPLING; TREATMENT OUTCOME; ACUTE DISEASE; BIBLIOGRAPHIC DATABASE; DRUG SURVEILLANCE PROGRAM; HEALTH SERVICES RESEARCH; INFORMATION PROCESSING; MEDICAL ERROR; METHODOLOGY; PSYCHOLOGICAL ASPECT; PUBLICATION; RISK MANAGEMENT; SAFETY;

ACUTE DISEASE; ADVERSE DRUG REACTION REPORTING SYSTEMS; DATA COLLECTION; DATABASES, BIBLIOGRAPHIC; HEALTH SERVICES RESEARCH; HUMANS; MEDICAL ERRORS; PERIODICALS; QUALITY ASSURANCE, HEALTH CARE; RESEARCH DESIGN; RISK MANAGEMENT; SAFETY MANAGEMENT;

EID: 0642307056     PISSN: 01606891     EISSN: None     Source Type: Journal    
DOI: 10.1002/nur.10103     Document Type: Review

References (100)

1. Abramson, N.S., Wald, K.S., Grenvik, A.N., Robinson, D., & Snyder, J.V. (1980). Adverse occurrences in intensive care units. JAMA, 244, 1582-1584.
2. Andrews, L.B., Stocking, C., Krizek, T., Gottlieb, L., Krizek, C., Vargish, T., et al. (1997). An alternative strategy for studying adverse events in medical care. Lancet, 349, 309-313.
3. Ansari, M.Z., Collopy, B.T., & McDonald, I.G. (1996). Establishing thresholds for adverse patient outcomes. International Journal for Quality in Health Care, 8, 223-230.
4. Arvidsson, S., Ouchterlony, J., Sjostedt, L., & Svardsudd, K. (1996). Predicting postoperative adverse events. Clinical efficiency of four general classification systems. The project perioperative risk. Acta Anaesthesiologica Scandinavica, 40, 783-791.
5. Bates, D.W., Makary, M.A., Teich, J.M., Pedraza, L., Ma'luf, N.M., Burstin, H., et al. (1998). Asking residents about adverse events in a computer dialogue: how accurate are they? Joint Commission Journal on Quality Improvement, 24, 197-202.
6. Bates, D.W., O'Neil, A.C., Boyle, D., Teich, J., Chertow, G.M., Komaroff, A.L., et al. (1994). Potential identifiability and preventability of adverse events using information systems. Journal of the American Medical Informatics Association, 1, 404-411.
7. Bates, D.W., O'Neil, A.C., Petersen, L.A., Lee, T.H., & Brennan, T.A. (1995). Evaluation of screening criteria for adverse events in medical patients. Medical Care, 33, 452-462.
8. Beckmann, U., Baldwin, I., Durie, M., Morrison, A., & Shaw, L. (1998). Problems associated with nursing staff shortage: An analysis of the first 3600 incident reports submitted to the Australian Incident Monitoring Study (AIMS-ICU). Anaesthesia and Intensive Care, 26, 396-400.
9. Beckmann, U., Baldwin, I., Hart, G.K., & Runciman, W.B. (1996). The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. An analysis of the first year of reporting. Anaesthesia and Intensive Care, 24, 320-329.
10. Beckmann, U., West, L.F., Groombridge, G.J., Baldwin, I., Hart, G.K., & Clayton, D.G., et al. (1996). The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care. Anaesthesia and Intensive Care, 24, 314-319.
11. Beddingfield, F.C., III, Uner, A.B., Kwon, H., & Baraff, L.J. (2000). A survey of nonphysician medical screening examinations in academic emergency medicine. Academy of Emergency Medicine, 7, 61-65.
12. Best, W.R., Khuri, S.F., Phelan, M., Hur, K., Henderson, W.G., Demakis, J.G., et al. (2002). Identifying patient preoperative risk factors and postoperative adverse events in administrative databases: Results from the Department of Veterans Affairs National Surgical Quality Improvement Program. Journal of the American College of Surgery, 194, 257-266.
13. Blegen, M.A., Goode, C.J., & Reed, L. (1998). Nurse staffing and patient outcomes. Nursing Research, 47, 43-50.
14. Blegen, M.A., & Vaughn, T. (1998). A multisite study of nurse staffing and patient occurrences. Nursing Economics, 16, 196-203.
15. Blegen, M.A., Vaughn, T.E., & Goode, C.J. (2001). Nurse experience and education: Effect on quality of care. Journal of Nursing Administration, 31, 33-39.
16. Bomhof, J., Arends, J.W., & van der Beek, J. (1993). Adverse patient occurrences in a university hospital: A comparison of screening results registered by specialists and by external review. Quality Assurance in Health Care, 5, 157-165.
17. Bomhof, J., Nieman, F.H., & Reerink, E. (1993). Registration of adverse patient occurrences in a university hospital: Relations between adverse patient occurrences and characteristics of hospitalized patients. Quality Assurance in Health Care, 5, 167-174.
18. Brennan, T.A., Hebert, L.E., Laird, N.M., Lawthers, A., Thorpe, K.E., Leape, L.L., et al. (1991). Hospital characteristics associated with adverse events and substandard care. JAMA, 265, 3265-3269.
19. Brennan, T.A., Leape, L.L., Laird, N.M., Hebert, L., Localio, A.R., Lawthers, A.G., et al. (1991). Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine, 324, 370-376.
20. Brennan, T.A., Localio, A.R., Leape, L.L., Laird, N.M., Peterson, L., Hiatt, H.H., et al. (1990). Identification of adverse events occurring during hospitalization. A cross-sectional study of litigation, quality assurance, and medical records at two teaching hospitals. Annals of Internal Medicine, 112, 221-226.
21. Brown, G.E. (1998). Redesign for effective quality assurance: Pilot program in an urban community hospital. American Journal of Medical Quality, 13, 141-146.
22. Burstin, H.R., Lipsitz, S.R., & Brennan, T.A. (1992). Socioeconomic status and risk for substandard medical care. JAMA, 268, 2383-2387.
23. Cary, A.H. (2001). Certified registered nurses: Results of the Study of the Certified Workforce. American Journal of Nursing, 101, 44-52.
24. Chen, P.P., Ma, M., Chan, S., & Oh, T.E. (1998). Incident reporting in acute pain management. Anaesthesia, 53, 730-735.
25. Cohen, M.M., O'Brien-Pallas, L.L., Copplestone, C., Wall, R., Porter, J., & Rose, D.K. (1999). Nursing workload associated with adverse events in the postanesthesia care unit. Anesthesiology, 91, 1882-1890.
26. Couch, N.P., Tilney, N.L., Rayner, A.A., & Moore, F.D. (1981). The high cost of low-frequency events: The anatomy and economics of surgical mishaps. New England Journal of Medicine, 304, 634-637.
27. Davis, P., Lay-Yee, R., Schug, S., Briant, R., Scott, A., Johnson, S., et al. (2001). Adverse events regional feasibility study: Indicative findings. New Zealand Medical Journal, 114, 203-205.
28. Dugan, J., Lauer, E., Bouquot, Z., Dutro, B.K., Smith, M., & Widmeyer, G. (1996). Stressful nurses: The effect on patient outcomes. Journal of Nursing Care Quality, 10, 46-58.
29. Elnicki, R.A., & Schmitt, J.P. (1980). Contribution of patient and hospital characteristics to adverse patient incidents. Health Services Research, 15, 397-414.
30. Elnitsky, C., Nichols, B., & Palmer, K. (1997). Are hospital incidents being reported? Journal of Nursing Administration, 27, 40-46.
31. Fischman, J. (2000, July 17). Making sure you're not the next mistake. U.S. News & World Report, 64.
32. Gagneux, E., Lombrail, P., Tropet, Y., Brientini, J.M., & Vichard, P. (1996). Incidence and preventability of adverse events in the emergency room of an orthopaedic traumatologie surgery unit. European Journal of Emergency Medicine, 3, 79-84.
33. Ganong, L.H. (1987). Integrative reviews of nursing research. Research in Nursing & Health, 10, 1-11.
34. Garcia-Martin, M., Lardelli-Claret, P., Bueno-Cavanillas, A., Luna-del-Castillo, J.D., Espigares-Garcia, M., & Galvez-Vargas, R. (1997). Proportion of hospital deaths associated with adverse events. Journal of Clinical Epidemiology, 50, 1319-1326.
35. Gawande, A.A., Thomas, E.J., Zinner, M.J., & Brennan, T.A. (1999). The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery, 126, 66-75.
36. Hall, J.C., & Hall, J.L. (1996). ASA status and age predict adverse events after abdominal surgery. Journal of Quality Clinical Practice, 16, 103-108.
37. Healey, M.A., Shackford, S.R., Osler, T.M., Rogers, F.B., & Burns, E. (2002). Complications in surgical patients. Archives of Surgery, 137, 611-617.
38. Jackson, G.B. (1980). Methods for integrative reviews. Review of Educational Research, 50, 438-460.
39. Johnson, W.G., Brennan, T.A., Newhouse, J.P., Leape, L.L., Lawthers, A.G., Hiatt, H.H., et al. (1992). The economic consequences of medical injuries. Implications for a no-fault insurance plan. JAMA, 267, 2487-2492.
40. Kobus, D.A., Amundson, D., Moses, J.D., Rascona, D., & Gubler, K.D. (2001). A computerized medical incident reporting system for errors in the intensive care unit: Initial evaluation of interrater agreement. Military Medicine, 166, 350-353.
41. Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
42. Kovner, C., & Gergen, P.J. (1998). Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image: Journal of Nursing Scholarship, 30, 315-321.
43. Kovner, C., Jones, C., Zhan, C., Gergen, P.J., & Basu, J. (2002). Nurse staffing and postsurgical adverse events: An analysis of administrative data from a sample of U.S. hospitals, 1990-1996. Health Services Research, 37, 611-629.
44. Lanska, D.J., & Hartz, A.J. (1998). Measurement of quality in health care. Neurology, 50, 584-587.
45. Leape, L.L., Brennan, T.A., Laird, N., Lawthers, A.G., Localio, A.R., Barnes, B.A., et al. (1991). The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine, 324, 377-384.
46. Lichtig, L.K., Knauf, R.A., & Milhoulland, D.K. (1999). Some impacts of nursing on acute care hospitals. Journal of Nursing Administration, 29, 25-33.
47. Lynn, M.R., & McMillen, B.J. (1999). Do nurses know what patients think is important in nursing care? Journal of Nursing Care Quality, 13, 65-74.
48. Maistrello, I., Di Pietro, P., Renna, S., & Rossi, R. (2001). Methodological and motivational factors affecting the surveillance of adverse events in hospitalized patients. American Journal of Medical Quality, 16, 107-109.
49. Maistrello, I., Febbrari, M.D., Tramontini, M., Maistrello, M., & Natale, L. (1995). The multipurpose surveillance-oriented medical record: A tool for quality of care management. International Journal for Quality in Health Care, 7, 399-405.
50. McLamb, J.T., & Huntley, R.R. (1967). The hazards of hospitalization. Southern Medical Journal, 60, 469-472.
51. McNeill, P.M., & Walton, M. (2002). Medical harm and the consequences of error for doctors. Medical Journal of Australia, 176, 222-225.
52. Meurier, C.E. (2000). Understanding the nature of errors in nursing: Using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event. Journal of Advanced Nursing, 32, 202-207.
53. Meurier, C.E., Vincent, C.A., & Parmar, D.G. (1998). Nurses' responses to severity dependent errors: A study of the causal attributions made by nurses following an error. Journal of Advanced Nursing, 27, 349-354.
54. Meurier, C.E., Vincent, C.A., & Parmar, D.G. (1997). Learning from errors in nursing practice. Journal of Advanced Nursing, 26, 111-119.
55. Mizrahi, T. (1984). Managing medical mistakes: Ideology, insularity and accountability among internists-in-training. Social Science and Medicine, 19, 135-146.
56. Muckart, D.J., Bhagwanjee, S., & Aitchison, J.M. (1994). Adverse events in a surgical intensive care unit - a cause of increased mortality. South African Journal of Surgery, 32, 69-73.
57. Narumi, J., Miyazawa, S., Miyata, H., Suzuki, A., Kohsaka, S., & Kosugi, H. (1999). Analysis of human error in nursing care. Accident Analysis and Prevention, 31, 625-629.
58. Neale, G., Woloshynowych, M., & Vincent, C. (2001). Exploring the causes of adverse events in NHS hospital practice. Journal of the Royal Society of Medicine, 94, 322-330.
59. Nettleman, M.D., & Nelson, A.P. (1994). Adverse occurrences during hospitalization on a general medicine service. Clinical Performance and Quality Health Care, 2, 67-72.
60. O'Hara, D.A., & Carson, N.J. (1997). Reporting of adverse events in hospitals in Victoria, 1994-1995. Medical Journal of Australia, 166, 460-463.
61. O'Neil, A.C., Petersen, L.A., Cook, E.F., Bates, D.W., Lee, T.H., & Brennan, T.A. (1993). Physician reporting compared with medical-record review to identify adverse medical events. Annals of Internal Medicine, 119, 370-376.
62. Petersen, L.A., Orav, E.J., Teich, J.M., O'Neil, A.C., & Brennan, T.A. (1998). Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Joint Commission Journal on Quality Improvement, 24, 77-87.
63. Pollock, J.R., & Hayward, R.D. (2001). Adverse operative events in neurosurgical training: Incidence, trends and proposals for prevention. British Journal of Neurosurgery, 15, 312-318.
64. The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. (1998). Quality first: Better health care for all Americans. Baltimore: U.S. Government Printing Office.
65. Redfern, S.J., & Norman, I.J. (1990). Measuring the quality of nursing care: A consideration of different approaches. Journal of Advanced Nursing, 15, 1260-1271.
66. Reed, L., Blegen, M.A., & Goode, C.S. (1998). Adverse patient occurrences as a measure of nursing care quality. Journal of Nursing Administration, 28, 62-69.
67. Rigby, K., Clark, R.B., & Runciman, W.B. (1999). Adverse events in health care: Setting priorities based on economic evaluation. Journal of Quality Clinical Practice, 19, 7-12.
68. Rose, D.K., Cohen, M.M., Wigglesworth, D.F., & Yee, D.A. (1992). Development of a computerized database for the study of anaesthesia care. Canadian Journal of Anaesthesia, 39, 716-723.
69. Runciman, W.B., Helps, S.C., Sexton, E.J., & Malpass, A. (1998). A classification for incidents and accidents in the health-care system. Journal of Quality Clinical Practice, 18, 199-211.
70. Schimmel, E.M. (1964). The hazards of hospitalization. Annals of Internal Medicine, 6, 100-110.
71. Sexton, J.B., Thomas, E.J., & Helmreich, R.L. (2000). Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. BMJ, 320, 745-749.
72. Shapiro, J.P. (1999, December 13). Doctoring a sickly system: Deadly medical mistakes are rampant. One expert thinks they can be avoided. U.S. News & World Report, 60-61.
73. Shulkin, D.J. (1995). The July phenomenon revisited: Are hospital complications associated with new house staff? American Journal of Medical Quality, 10, 14-17.
74. Silber, J.H., Williams, S.V., Krakauer, H., & Schwartz, J.S. (1992). Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Medical Care, 30, 615-629.
75. Sochalski, J. (2001). Quality of care, nurse staffing, and patient outcomes. Policy, Politics, & Nursing Practice, 2, 9-18.
76. Stearley, H.E. (1998). Patients' outcomes: Intrahospital transportation and monitoring of critically ill patients by a specially trained ICU nursing staff. American Journal of Critical Care, 7, 282-287.
77. Steel, K., Gertman, P.M., Crescenzi, C., & Anderson, J. (1981). Iatrogenic illness on a general medical service at a university hospital. New England Journal of Medicine, 304, 638-642.
78. Stetler, C.B., Morsi, D., & Burns, M. (2000). Physical and emotional patient safety. A different look at nursing-sensitive outcomes. Outcomes Management for Nursing Practice, 4, 159-165.
79. Thomas, E.J., Studdert, D.M., Burstin, H.R., Orav, E.J., Zeena, T., Williams, E.J., et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care, 38, 261-271.
80. Thomas, E.J., Studdert, D.M., Newhouse, J.P., Zbar, B.I., Howard, K.M., Williams, E.J., et al. (1999). Costs of medical injuries in Utah and Colorado. Inquiry, 36, 255-264.
81. Tuttle, D., Panzer, R.J., & Baird, T. (1998). Using administrative data to improve compliance with mandatory state event reporting. Joint Commission Journal on Quality & Safety, 28, 349-358.
82. Vincent, C., Neale, G., & Woloshynowych, M. (2001). Adverse events in British hospitals: Preliminary retrospective record review. BMJ, 322, 517-519.
83. Vincent, C., Stanhope, N., & Crowley-Murphy, M. (1999). Reasons for not reporting adverse incidents: An empirical study. Journal of Evaluation in Clinical Practice, 5, 13-21.
84. Walshe, K. (2000). Adverse events in health care: Issues in measurement. Quality in Health Care, 9, 47-52.
85. Walshe, K., Bennett, J., & Ingram, D. (1995). Using adverse events in health-care quality improvement: Results from a British acute hospital. International Journal of Health Care Quality Assurance, 8, 7-14.
86. Wanzel, K.R., Jamieson, C.G., & Bohnen, J.M. (2000). Complications on a general surgery service: Incidence and reporting. Canadian Journal of Surgery, 43, 113-117.
87. Webb, R.K., Currie, M., Morgan, C.A., Williamson, J.A., Mackay, P., Russell, W.J., et al. (1993). The Australian Incident Monitoring Study: An analysis of 2000 incident reports. Anaesthesia and Intensive Care, 21, 520-528.
88. Weingart, S.N., Callanan, L.D., Ship, A.N., & Aronson, M.D. (2001). A physician-based voluntary reporting system for adverse events and medical errors. Journal of General Internal Medicine, 16, 809-814.
89. Weingart, S.N., Ship, A.N., & Aronson, M.D. (2000). Confidential clinician-reported surveillance of adverse events among medical inpatients. Journal of General Internal Medicine, 15, 470-477.
90. Welsh, C.H., Pedot, R., & Anderson, R.J. (1996). Use of morning report to enhance adverse event detection. Journal of General Internal Medicine, 8, 454-460.
91. Williamson, J.A., Webb, R.K., Sellen, A., Runciman, W.B., & Van der Walt, J.H. (1993). The Australian Incident Monitoring Study. Human failure: An analysis of 2000 incident reports. Anaesthesia and Intensive Care, 21, 678-683.
92. Wilson, R.M., Harrison, B.T., Gibberd, R.W., & Hamilton, J.D. (1999). An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Medical Journal of Australia, 170, 411-415.
93. Wilson, R.M., Runciman, W.B., Gibberd, R.W., Harrison, B.T., Newby, L., & Hamilton, J.D. (1995). The Quality in Australian Health Care Study. Medical Journal of Australia, 163, 458-471.
94. Wolff, A.M. (1992). Limited adverse occurrence screening. A medical quality control system for medium sized hospitals. Medical Journal of Australia, 156, 449-452.
95. Wolff, A.M. (1995). Limited adverse occurrence screening: An effective and efficient method of medical quality control. Journal of Quality Clinical Practice, 15, 221-233.
96. Wolff, A.M. (1996). Limited adverse occurrence screening: Using medical record review to reduce hospital adverse patient events. Medical Journal of Australia, 164, 458-461.
97. Wolff, A.M., & Bourke, J. (2002). Detecting and reducing adverse events in an Australian rural base hospital emergency department using medical record screening and review. Emergency Medicine Journal, 19, 35-40.
98. Wolff, A.M., Bourke, J., Campbell, I.A., & Leembruggen, D.W. (2001). Detecting and reducing hospital adverse events: Outcomes of the Wimmera clinical risk management program. Medical Journal of Australia, 174, 621-625.
99. Wu, A.W., Folkman, S., McPhee, S.J., & Lo, B. (1991). Do house officers learn from their mistakes? JAMA, 265, 2089-2094.
100. Wu, A.W., Folkman, S., McPhee, S.J., & Lo, B. (1993). How house officers cope with their mistakes. Western Journal of Medicine, 159, 565-569.