Can we use incident reports to detect hospital adverse events?

Journal of Patient Safety

Volumn 4, Issue 1, 2008, Pages 9-12

  Blais, Régis ^a   Bruno, Derson ^a   Bartlett, Gillian ^b   Tamblyn, Robyn ^b  

^a UNIVERSITÉ DE MONTRÉAL   (Canada)

^b MCGILL UNIVERSITY   (Canada)

Author keywords

Adverse events; Chart review; Hospital; Incident reports

Indexed keywords

EID: 41849137599     PISSN: 15498417     EISSN: 15498425     Source Type: Journal    
DOI: 10.1097/PTS.0b013e31816154a4     Document Type: Article

References (24)

1. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study l. N Engl J Med. 1991;324:370-377.
2. Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australia health care study. Med J Aust. 1995;163:458-476.
3. Baker GR, Norton PG, Flintoft V, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J. 2004;170:1678-1686.
4. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261-271.
5. Davis P, Lay-Yee R, Briant R, et al. Adverse events in New Zealand public hospitals I: occurrence and impact. N Z Med J. 2002;115:U271.
6. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
7. Wald H, Shojania KG. Root Cause Analysis in Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Summary. 2001, AHRQ Publication No. 01-E057. Rockville, MD: Agency for Healthcare Research and Quality; 2001.
8. Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21:541-548.
9. Kavaler F, Spiegel AD. Risk Management in Health Care Institutions. A Strategic Approach. Sudbury: Jones and Bartlett; 1997.
10. Beckmann U, Bohringer C, Carless R, et al. Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Crit Care Med. 2003;31:1006-1011.
11. O'Neil AC, Petersen LA, Cook F, et al. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993;119:370-376.
12. Sari ABA, Sheldon TA, Cracknell A, et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ, doi:10.1136/bmj.39031.507153.AE (published 15 December 2006).
13. Stanhope N, Crowley-Murphy M, Vincent C, et al. An evaluation of adverse incident reporting. J Eval Clin Pract. 1999;5:5-12.
14. Taylor JA, Brownstein D, Christakis DA, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics. 2004;114:729-735.
15. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. Br Med J. 2001;322:517-519.
16. Silver MS. Incident review management: a systemic approach to performance improvements. J Healthc Qual. 1999;21:21-27.
17. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract. 1999;5:13-21.
18. Currie M, Pybus DA, Torda TA. A prospective study of anaesthetic critical events: a report on a pilot study of 88 cases. Anaesth Intensive Care. 1989;16:98-100.
19. Evans SM, Berry JG, Smith, BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15:39-43.
20. Uribe CL, Schweikhart SB, Pathak DS, et al. Barriers to medical-error reporting: an exploratory investigation. J Healthc Manag. 2002;47:263-279.
21. Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2000;15:470-477.
22. Leape LL. Why should we report adverse incidents? J Eval Clin Pract. 1999;5:1-4.
23. Helmreich RL, Merritt AC. Culture at Work in Aviation and Medicine: National, Organizational and Professional Influences. Aldershot, Hampshire: Ashgate; 1998.
24. Institute of Medicine. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academies Press; 2004.