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Adverse events in healthcare: learning from mistakes

Doctors on ward

Adverse events in healthcare: learning from mistakes

Rafter N, Hickey A, Condell S, Conroy R, O'Connor P, Vaughan D, et al

Large national reviews of patient charts estimate that approximately 10% of hospital admissions are associated with an adverse event (defined as an injury resulting in prolonged hospitalization, disability or death, caused by healthcare management). Apart from having a significant impact on patient morbidity and mortality, adverse events also result in increased healthcare costs due to longer hospital stays. Furthermore, a substantial proportion of adverse events are preventable.

Through identifying the nature and rate of adverse events, initiatives to improve care can be developed. A variety of methods exist to gather adverse event data both retrospectively and prospectively but these do not necessarily capture the same events and there is variability in the definition of an adverse event. For example, hospital incident reporting collects only a very small fraction of the adverse events found in retrospective chart reviews. Until there are systematic methods to identify adverse events, progress in patient safety cannot be reliably measured.

This review looks at the need for a safety culture, how we should measure adverse events, and why current adverse event monitoring is unable to demonstrate trends in patient safety.

It was published in QJM, the monthly journal of the Association of Physicians, in August 2014.