Prevalence and consequences of patient safety incidents in general practice in the Netherlands: a retrospective medical record review study

Implementation Science

Volumn 6, Issue 1, 2011, Pages

  Gaal, Sander ^a   Verstappen, Wim ^a   Wolters, René ^a   Lankveld, Henrike ^a   van Weel, Chris ^a   Wensing, Michel ^a  

^a RADBOUD UNIVERSITY MEDICAL CENTER   (Netherlands)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; GENERAL PRACTICE; HUMAN; MEDICAL AUDIT; MEDICAL ERROR; MORALITY; NETHERLANDS; PATIENT SAFETY; PREVALENCE; STANDARD; STATISTICS;

GENERAL PRACTICE; HUMANS; MEDICAL AUDIT; MEDICAL ERRORS; NETHERLANDS; PATIENT SAFETY; PREVALENCE; RETROSPECTIVE MORAL JUDGMENT;

EID: 79953667147     PISSN: None     EISSN: 17485908     Source Type: Journal    
DOI: 10.1186/1748-5908-6-37     Document Type: Article

References (27)

1. Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The "To Err is Human" report and the patient safety literature. Qual Saf Health Care 2006, 15(3):174-178. 10.1136/qshc.2006.017947, 2464859, 16751466.
2. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005, 83(3):457-502. 10.1111/j.1468-0009.2005.00409.x, 16202000.
3. Gandhi TK, Lee TH. Patient safety beyond the hospital. N Engl J Med 2010, 363(11):1001-1003. 10.1056/NEJMp1003294, 20825311.
4. Ministry of Health Welfare and Sport Primary health care in the Netherlands. International Publication Series Health Welfare and Sport no 20 2005, 15-2-2010, Ministry of Health Welfare and Sport.
5. Fournier AM. Primary care remuneration--a simple fix. N Engl J Med 2009, 361(10):e102. 10.1056/NEJMopv0907129, 19692678.
6. van der Wal G. Medical disciplinary jurisprudence in The Netherlands; a 10-year review. Ned Tijdschr Geneeskd 1996, 140(52):2640-2644.
7. Olsen S, Neale G, Schwab K, Psaila B, Patel T, Chapman EJ, 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. Qual Saf Health Care 2007, 16(1):40-44. 10.1136/qshc.2005.017616, 2464933, 17301203.
8. Wetzels R, Wolters R, van Weel C, Wensing M. Mix of methods is needed to identify adverse events in general practice: a prospective observational study. BMC Fam Pract 2008, 9:35. 10.1186/1471-2296-9-35, 2440745, 18554418.
9. Fernald DH, Pace WD, Harris DM, West DR, Main DS, Westfall JM. Event reporting to a primary care patient safety reporting system: a report from the ASIPS collaborative. Ann Fam Med 2004, 2(4):327-332. 10.1370/afm.221, 1466702, 15335131.
10. Plews-Ogan ML, Nadkarni MM, Forren S, Leon D, White D, Marineau D, et al. Patient safety in the ambulatory setting. A clinician-based approach. J Gen Intern Med 2004, 19(7):719-725. 10.1111/j.1525-1497.2004.30386.x, 1492477, 15209584.
11. Sandars J, Esmail A. The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract 2003, 20(3):231-236. 10.1093/fampra/cmg301, 12738689.
12. Zegers M, de Bruijne MC, Wagner C, Hoonhout LH, Waaijman R, Smits M, et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care 2009, 18(4):297-302. 10.1136/qshc.2007.025924, 19651935.
13. Harmsen M, Gaal S, van Dulmen S, de Feijter E, Giesen P, Jacobs A, et al. Patient safety in Dutch primary care: study protocol. Implementation Science 2010, 5(50). 2914083, 20584268.
14. Gaal S, Verstappen W, Wensing M. Patient safety in primary care: a survey of general practitioners in The Netherlands. BMC Health Serv Res 2010, 10:21. 10.1186/1472-6963-10-21, 2823738, 20092616.
15. Wagner C, van der Wal G. Voor een goed begrip. Bevordering patiëntveiligheid vraagt om heldere definities. [For a good understanding. Improving Patient Safety requires clear definitions]. Med Contact 2005, 60:1888-1891.
16. Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007, 334(7584):79. 10.1136/bmj.39031.507153.AE, 1767248, 17175566.
17. Snijders C, van der Schaaf TW, Klip H, van Lingen WPFF, Molendijk A. Feasibility and reliability of PRISMA-medical for specialty-based incident analysis. Qual Saf Health Care 2009, 18(6):486-491. 10.1136/qshc.2008.028068, 19955462.
18. The Linnaeus-PC Collaboration International taxonomy of medical errors in primary care - version 2. 2002, Washington, DC, The Robert Graham Center, The Linnaeus-PC Collaboration.
19. Smits M, Janssen J, de VR, Zwaan L, Timmermans D, Groenewegen P, et al. Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. Int J Qual Health Care 2009, 21(4):292-300. 10.1093/intqhc/mzp023, 19542181.
20. World Health Organization Alliance for Patient Safety Project to develop the international patient safety event taxonomy: updated review of the literature 2003-2005. 2005, Geneva, World Health Organization, World Health Organization Alliance for Patient Safety.
21. World Health Organization Alliance for Patient Safety The conceptual framework of an international patient safety event classification: executive summary. 2010, Geneva, World Health Organization, World Health Organization Alliance for Patient Safety.
22. Lilford RJ, Mohammed MA, Braunholtz D, Hofer TP. The measurement of active errors: methodological issues. Qual Saf Health Care 2003, 12(Suppl 2):ii8-12. 1765778, 14645889.
23. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008, 17(3):216-223. 10.1136/qshc.2007.023622, 2569153, 18519629.
24. Zwaan L, de Bruijne M, Wagner C, Thijs A, Smits M, van der Wal G, et al. Patient Record Review of the Incidence, Consequences, and Causes of Diagnostic Adverse Events. Arch Intern Med 2010, 170(12):1015-1021. 10.1001/archinternmed.2010.146, 20585065.
25. Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care--a systematic review. Fam Pract 2008, 25(6):400-413. 10.1093/fampra/cmn071, 18842618.
26. Koskela TH, Ryynanen OP, Soini EJ. Risk factors for persistent frequent use of the primary health care services among frequent attenders: A Bayesian approach. Scand J Prim Health Care 2010, 28(1):55-61. 10.3109/02813431003690596, 20331389.
27. Fischhoff B. Hindsight not equal to foresight: the effect of outcome knowledge on judgment under uncertainty. Qual Saf Health Care 2003, 12(4):304-311. 10.1136/qhc.12.4.304, 1743746, 12897366.