What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents

Journal of General Internal Medicine

Volumn 20, Issue 9, 2005, Pages 830-836

  Weingart, Saul N ^a,b,c   Pagovich, Odelya ^d   Sands, Daniel Z ^b,c,e   Li, Joseph M ^b,c   Aronson, Mark D ^b,c   Davis, Roger B ^b,c   Bates, David W ^c,f   Phillips, Russell S ^b,c  

^a DANA FARBER CANCER INSTITUTE   (United States)

^b BETH ISRAEL DEACONESS MEDICAL CENTER   (United States)

^c HARVARD MEDICAL SCHOOL   (United States)

^d TEL AVIV UNIVERSITY   (Israel)

^e Zix Corporation   (United States)

^f BRIGHAM AND WOMEN S HOSPITAL   (United States)

Author keywords

Adverse event; Incident reporting; Medical error; Patient participation

Indexed keywords

ADULT; AGED; ARTICLE; COHORT ANALYSIS; CONTROLLED STUDY; DRUG HYPERSENSITIVITY; FEMALE; HOSPITAL PATIENT; HOSPITALIZATION; HUMAN; INCIDENTAL FINDING; INTERVIEW; LEARNING; MAJOR CLINICAL STUDY; MALE; MEDICAL ERROR; MEDICAL RECORD; POISSON DISTRIBUTION; TEACHING HOSPITAL; TELEPHONE;

ADULT; AGED; AGED, 80 AND OVER; BOSTON; FEMALE; HEALTH CARE SURVEYS; HOSPITALS, TEACHING; HUMANS; INTERVIEWS; MALE; MEDICAL ERRORS; MEDICATION ERRORS; MIDDLE AGED; PATIENT SATISFACTION; PROCESS ASSESSMENT (HEALTH CARE); PROSPECTIVE STUDIES;

EID: 28444482120     PISSN: 08848734     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1525-1497.2005.0180.x     Document Type: Article

References (33)

1. Institute for Family-Centered Care. Your Role in Safe Medication Use. Boston, Mass: Massachusetts Coalition for the Prevention of Medical Errors; 1999. Available at: http://www.macoalition.org/documents/ Best_Practice_Medication_Errors.pdf. Accessed December 14, 2003.
2. American Hospital Association. Successful practices for improving medication safety, 1999. Available at: http://www.hospitalconnect.com/aha/ key_issues/medication_safety/ahainitiative/medicalsafety20015.html. Accessed December 14, 2004.
3. National Patient Safety Foundation. You can help improve patient safety. Available at: http://www.npsf.org/html/patients.html. Accessed January 20, 2003.
4. National Patient Safety Foundation. National Agenda for Action: Patients and Families in Patient Safety, 2003. Available at: http://www.npsf.org/ download/AgendaFamilies.pdf. Accessed December 14, 2003.
5. Agency for Healthcare Research and Quality. 20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38. Rockville, Md: Agency for Healthcare Research and Quality: 2000. Available at: http://www.ahrq.gov/consumer/20tips.htm. Accessed December 14, 2003.
6. Davies RD, Ware JE. Involving consumers in quality of care assessment. Health Affairs. 1998;33-48.
7. Cleary PD, Edgman-Levitan S, Roberts M, et al. Patients evaluate their hospital care: a national survey. Health Affairs. 1991;11:254-67.
8. Cleary PD, Edgman-Levitan S. Health care quality: incorporating consumer perspectives. JAMA. 1997;278:1608-12.
9. Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003;138:33-9.
10. Public opinion of patient safety issues: research findings. Report prepared by Louis Harris and Associates for the National Patient Safety Foundation at the AMA. Chicago, Ill: National Patient Safety Foundation, 1997. Available at: http://www.npsf.org/download/1997survey.pdf. Accessed December 14, 2003.
11. How safe is your hospital? Consumer reports readers rate the care they or a relative received. Consumer Rep. 2002;68:12-8.
12. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347: 1933-40.
13. Gandhi TK, Weingart SN, Peterson J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556-64.
14. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996;335:1963-7.
15. Studdert DM, Thomas EJ, Burstin HR, Zbar BI, Orav EJ, Brennan TA. Negligent care and malpractice claiming behavior in Utah and Colorado. Med Care. 2000;38:250-60.
16. Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2000;15:470-7.
17. Weingart SN, Callanan LD, Ship AN, Aronson MD. A physician-based voluntary reporting system for adverse events and medical errors. J Gen Intern Med. 2001;16:809-14.
18. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7.
19. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646-51.
20. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274:29-34.
21. Kenagy JW, Berwick DM, Shore MF. Service quality in health care. JAMA. 1999;281:661-5.
22. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med. 1991;324:370-76.
23. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261-71.
24. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322:517-9.
25. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust. 1995;163:458-71.
26. Thomas EJ, Studdert DM, Runciman WB, et al. A comparison of iatrogenic injury studies in Australia and the USA: context, methods, casemix, population, patient and hospital characteristics. Int J Qual Health Care. 2000;12:371-8.
27. Runciman WB, Webb RK, Helps SC, et al. A comparison of iatrogenic injury studies in Australia and the USA: reviewer behaviour and quality of care. Int J Qual Health Care. 2000;12:379-88.
28. Bates DW. A 40-year-old woman who noticed a medication error. JAMA. 2001;285:3134-40.
29. Pizzi LT, Goldfarb NI, Nash DB. Other practices related to patient participation. Ch. 50. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No. 43. Rockville, Md: US Agency for Healthcare Research and Quality; 2001;575-8.
30. O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993;119:370-6.
31. Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc. 1998;5:305-14.
32. Field TS, Gurwitz JH, Avorn J, et al. Risk factors for adverse drug events among nursing home residents. Arch Intern Med. 2001;161: 1629-34.
33. Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA. 2003;290:1899-905.