A new, evidence-based estimate of patient harms associated with hospital care

Journal of Patient Safety

Volumn 9, Issue 3, 2013, Pages 122-128

  James, John T ^a  

^a Patient Safety America   (United States)

Author keywords

Global Trigger Tool; medical errors; patient harm; patient centered care; preventable adverse events; transparency

Indexed keywords

HOSPITALIZATION; HUMAN; MEDICAL ERROR; MEDICAL RECORD; PATIENT HARM; REVIEW; STATISTICS; UNITED STATES;

HOSPITALIZATION; HUMANS; MEDICAL ERRORS; MEDICAL RECORDS; PATIENT HARM; UNITED STATES;

EID: 84883654527     PISSN: 15498417     EISSN: 15498425     Source Type: Journal    
DOI: 10.1097/PTS.0b013e3182948a69     Document Type: Review

References (43)

1. Zilberberg MD. The clinical research enterprise-time to change course? JAMA. 2011;305:604-605.
2. IOM (Institute of Medicine). Redesigning Continuing Education in the Health Professions. Washington, DC: The National Academies Press; 2010.
3. Sniderman AD, Furberg CD Why guideline-making requires reform. JAMA. 2009;301:429-431.
4. Ferket BS, Colkesen EB, Visser J.J., et al Systematic review of guidelines on cardiovascular risk assessment. Arch Intern Med. 2010;170:27-40.
5. Mendelson TB, Meltzer M, Campbell E.G., et al Conflicts of interest in cardiovascular clinical practice guidelines. Arch Intern Med. 2011;171:577-585.
6. Gittell JH. High Performance Healthcare-Using the Power of Relationships to Achieve Quality, Efficiency and Resilience. New York, NY: McGraw Hill; 2009
7. American College of Physicians. Achieving a high performance health care system with universal access: What the United States can learn from other countries. Ann Intern Med. 2008;148:55-75.
8. Reid, RO, Friedberg MW, Adams J.L., et al Associations between physician characteristics and quality of care. Arch Intern Med. 2010;170:1442-1449.
9. Levinson DR. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. DHHS, OIG. 2012, OEI-06-09-00091.
10. California Injury Lawyers Blog. Available at: http://www. californiainjurylawyersblog.com/2009/06/california-medical-malpractice-dennis- quaids-twins-to-receive-500000-for-heparin-overdose.html. Accessed July 12, 2012.
11. McKnight EV, Bennington TT A Never Event-Exposing the Largest Outbreak of Hepatitis C in American Healthcare History. Fremont, NE: History Examined, LLC; 2010
12. Ghandi TK, Zuccotti G, Lee TH Incomplete care-On the trail of flaws in the system. N Engl J Med. 2011:365:486-488.
13. Gheorghaide M, Gattis WA, O'Conner CM. Treatment gaps in the pharmacologic management of heart failure. Rev Cadiovasc Med. 2002;3:S11-S19.
14. Weismann JS, Schneider EC, Weingart S.N., et al Comparing patient-reported hospital adverse events with medical records reviews: Do patients know something that hospitals do not? Ann Intern Med. 2008;149:100-108. (Pubitemid 352008597)
15. James JT. A Sea of Broken Hearts-Patient Rights in a Dangerous, Profit-Driven Health Care System. Bloomington, IN: AuthorHouse; 2007.
16. Weiner SJ, Schwartz A, Weaver F., et al Contextual errors and failures in individualizing patient care. Ann Intern Med. 2010;153:69-75.
17. Welch HG, Schwartz LM, Woloshin S. Over-diagnosed-Making People Sick in the Pursuit of Health. Boston, MA: Beacon Press; 2011.
18. Classen, DC, Resar R, Griffin F., et al. "Global trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff. 2011;30:581-589.
19. Parry G, Cline A, Goldmann D. Deciphering harm measurement. JAMA. 2012;307:2155-2156.
20. Walter D. Collateral DamageVA Patient, a New Procedure, and the Learning Curve. Charleston, SC: CreateSpace; 2010.
21. Institute for Healthcare Improvement. IHI Global Trigger Tool Guide. Cambridge MA, 2008. Available at: http://www.ihi.org/knowledge/Pages/Tools/ IHIGlobalTriggerToolforMeasuringAEs.aspx. Accessed July 12, 2012.
22. Department of Health and Human Services, Office of the Inspector General. Adverse Events in Hospitals: Case Study of Incidence among Medicare Beneficiaries in Two Selected Counties. Washington, DC; 2008, Available at: http://oig.hhs.gov/oei/reports/OEI-06-08-00220.pdf.
23. Department of Health and Human Services, Office of the Inspector General. Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries. Washington, DC; 2010, Available at: http://oig.hhs.gov/oei/reports/OEI-06-09- 00090.pdf.
24. Landrigan, CP, Parry GJ, Bones C.B., et al Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124-2134.
25. IOM (Institute of Medicine). To Err is Human-Building a Safer Health System. Washington, DC: The National Academies Press; 2000.
26. Hall MJ, DeFrances CJ, Williams S.N., et al National Health Statistics Report. CDC Report Number 29; 2010. Available at: http://www.cdc.gov/nchs/data/ nhsr/nhsr029.pdf.
27. Hayward RA, Hofer TP Estimating hospital deaths due to medical errors. JAMA. 2001;286:415-420.
28. Goodman JC, Villarreal P, Jones B. The social cost of adverse medical events, and what we can do about it. Health Aff. 2011;30:590-595.
29. Brennan TA, Leape LL, Laird N.M., et al Incidence of adverse events and negligence in hospital patients: results of the Harvard Medical Practice Study. N Engl J Med. 1991;324:370-376.
30. IOM (Institute of Medicine). Patient Safety-Achieving a New Standard of Care. Washington, DC: The National Academies Press; 2004.
31. Moody J, Cosgrove SE, Olmsted R, et al Antimicrobial stewardship: a collaborative partnership between infection preventionists and healthcare epidemiologists. Infect Control Hosp Epidemiol. 2012;33:328-330.
32. Schneider EL, Campese VM Adverse drug responses, an increasing threat to the well-being of older patients. Arch Intern Med. 2010;170:1148-1149.
33. Stergiopoulos K, Brown DL Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease. Arch Intern Med. 2012;172:312-319.
34. Newman-Toker D.E., Pronovost PJ Diagnostic errors-the next frontier for patient safety. JAMA. 2009;301:1060-1062.
35. Kotchen TA. Why the slow diffusion of treatment guidelines into clinical practice? Arch Intern Med. 2007;167:2394-2395. (Pubitemid 350254898)
36. A randomized trial of propranolol in patients with acute myocardial infarction. I. Mortality results. JAMA. 1982;247:1707-14. Available at: http://www.ncbi.nlm.nih.gov/pubmed/7038157.
37. Dunlay SM, Alexander KP, Melloni C, et al Medical records and quality of care in acute coronary syndromes. Arch Intern Med. 2008; 168:1692-1698.
38. Leape L. Institute of Medicine medical error figures are not exaggerated. JAMA. 2000;284:95-97. (Pubitemid 30445670)
39. Weingart SN, Wilson RM, Gibberd R.W., et al Epidemiology of medical error. BMJ. 2000:320:774-777. (Pubitemid 30179431)
40. Flynn EA, Barker KN, Pepper G.A., et al Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health-System Pharm. 2002;59:436-446. (Pubitemid 34208608)
41. Campbell EG, Regan S, Gruen R.L., et al Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007; 147:795-802. (Pubitemid 351664442)
42. Junya Z, Struver S, Epstein A., et al Can we rely on patients' reports of adverse events? Med Care. 2011;49:948-955.
43. Rogan GN, Sebat F, Grady I. How Peer Review Failed at Redding Medical Center, Why It Is Failing Across the Country and What Can be Done About It. Congressional Report, June 1, 2008. Available at: http://www. allianceforpatientsafety.org/redding-failure.pdf. Accessed July 12, 2012.