Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system

International Journal for Quality in Health Care

Volumn 26, Issue 4, 2014, Pages 418-425

  Backman, Chantal ^a,b   Forster, Alan J ^b,c   Vanderloo, Saskia ^b  

^a UNIVERSITY OF OTTAWA   (Canada)

^b OTTAWA HOSPITAL RESEARCH INSTITUTE   (Canada)

^c UNIVERSITY OF OTTAWA   (Canada)

Author keywords

Prospective surveillance; Safety management methods; Sentinel surveillance

Indexed keywords

CLINICAL TRIAL; HEALTH CARE QUALITY; HOSPITAL MANAGEMENT; HUMAN; INFORMATION PROCESSING; MULTICENTER STUDY; ORGANIZATION AND MANAGEMENT; PROGRAM EVALUATION; PROSPECTIVE STUDY; SAFETY; TOTAL QUALITY MANAGEMENT;

DATA COLLECTION; HEALTH FACILITY ADMINISTRATION; HUMANS; PROGRAM EVALUATION; PROSPECTIVE STUDIES; QUALITY IMPROVEMENT; QUALITY INDICATORS, HEALTH CARE; SAFETY MANAGEMENT;

EID: 84905827124     PISSN: 13534505     EISSN: 14643677     Source Type: Journal    
DOI: 10.1093/intqhc/mzu052     Document Type: Article

References (31)

1. Wilson RM, Runciman WB, Gibberd RW et al. The Quality in Australian Health Care Study. Med J Aust 1995;163:458-71.
2. 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.
3. Baker GR, Norton PG, Flintoft V et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170:1678-86.
4. Forster AJ, Asmis TR, Clark HD et al. Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. CMAJ 2004;170:1235-40.
5. Brennan TA, Leape LL, Laird NM et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.
6. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-9.
7. de Vries EN, Ramrattan MA, Smorenburg SM et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216-23.
8. Forster AJ, Dervin G, Martin C et al. Improving patient safety through the systematic evaluation of patient outcomes. Can J Surg 2012;55:418-25.
9. Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: an elusive target. JAMA 2006;296:696-9.
10. Naessens JM, Campbell CR, Huddleston JM et al. A comparison of hospital adverse events identified by three widely used detection methods. Int J Qual Health Care 2009;21:301-7.
11. Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med 2003;18:61-7.
12. AHRQ Quality Indicators. Guide to Patient Safety Indicators. Version 2.1 ed. Rockville, MD: Agency for Healthcare Research and Quality, 2005.
13. 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;21:541-8.
14. Romano PS, Chan BK, Schembri ME et al. Can administrative data be used to compare postoperative complication rates across hospitals? Med Care 2002;40:856-67.
15. Rosen AK, Zhao S, Rivard P et al. Tracking rates of patient safety indicators over time: lessons from the Veterans Administration. Med Care 2006;44:850-61.
16. Rosen AK, Rivard P, Zhao S et al. Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration data? Med Care 2005;43:873-84.
17. Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med 1993;8:289-94.
18. Bates DW, Cullen DJ, Laird N et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995;274:29-34.
19. Forster AJ, Halil RB, Tierney MG. Pharmacist surveillance of adverse drug events. Am J Health Syst Pharm 2004;61:1466-72.
20. Forster AJ, Worthington JR, Hawken S et al. Using prospective clinical surveillance to identify adverse events in hospital. BMJ Qual Saf 2011;20:756-63.
21. Forster AJ, Fung I, Caughey S et al. Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol 2006;108:1073-83.
22. Forster AJ, Kyeremanteng K, Hooper J et al. The impact of adverse events in the intensive care unit on hospital mortality and length of stay. BMC Health Serv Res 2008;8:259.
23. Iyengar A, Baxter A, Forster A. Using Medical Emergency Teams to detect preventable adverse events. Crit Care 2009;13:R126.
24. Sorensen AV, Harrison MI, Kane HL et al. From research to practice: factors affecting implementation of prospective targeted injury-detection systems. BMJ Qual Saf 2011;20:527-33.
25. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349-57.
26. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277-88.
27. Donchin Y, Gopher D, Olin M et al. A look into the nature and causes of human errors in the intensive care unit. Qual Saf Health Care 2003;12:143-7; discussion 147-8.
28. Weingart SN, Iezzoni LI, Davis RB et al. Use of administrative data to find substandard care: validation of the complications screening program. Med Care 2000;38:796-806.
29. McCarthy EP, Iezzoni LI, Davis RB et al. Does clinical evidence support ICD-9-CM diagnosis coding of complications? Med Care 2000;38:868-76.
30. Langley GJ, Moen R, Nolan TW et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd edn. San Francisco: Jossey-Bass, 2009.
31. Pronovost P, Weast B, Rosenstein B et al. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 2005;1:33-40.