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Journal of General Internal Medicine

, Volume 18, Issue 1, pp 61–67 | Cite as

Measuring errors and adverse events in health care

  • Eric J. Thomas
  • Laura A. Petersen
Perspectives

Abstract

In this paper, we identify 8 methods used to measure errors and adverse events in health care and discuss their strengths and weaknesses. We focus on the reliability and validity of each, as well as the ability to detect latent errors (or system errors) versus active errors and adverse events. We propose a general framework to help health care providers, researchers, and administrators choose the most appropriate methods to meet their patient safety measurement goals.

Key words

medical error adverse events patient safety measurement 

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References

  1. 1.
    Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human. Washington DC: National Academy Press, 1999.Google Scholar
  2. 2.
    Expert Group on Learning from Adverse Events in the NHS. An Organisation With a Memory. London: Stationery Office; 2000.Google Scholar
  3. 3.
    Bates DW, Gawande AA. Error in medicine: what have we learned. Ann Intern Med. 2000;132:763–7.PubMedGoogle Scholar
  4. 4.
    Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology of medical error. BMJ. 2000;320:774–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Brennan TA. The Institute of Medicine report on medical errors—could it do harm? N Engl J Med. 2000;342:1123–5.PubMedCrossRefGoogle Scholar
  6. 6.
    McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA. 2000;284:93–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Sox HC, Woloshin S. How many deaths are due to medical error? Getting the number right. Eff Clin Pract. 2000;3:277–83.Google Scholar
  8. 8.
    Hofer TP, Kerr EA. What is an error? Eff Clin Pract. 2000;3:261–9.PubMedGoogle Scholar
  9. 9.
    Wears RL, Janiak B, Moorehead JC, et al. Human error in medicine: promise and pitfalls, part 2. Ann Emerg Med. 2000;36:142–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Leape LL, Berwick DM, Bates DW. What practices will most improve patient safety? Evidence-based medicine meets patient safety. JAMA. 2002;288:501–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Shojania KG, Duncan BW, McDonald KM, Wachter RM. Safe but sound. Patient safety meets evidence-based medicine. JAMA. 2002;288:508–13.PubMedCrossRefGoogle Scholar
  12. 12.
    Reason J. Human Error. Cambridge: Cambridge University Press; 1990.Google Scholar
  13. 13.
    Hulley SB, Martin JN, Cummings SR. Planning the measurements: precision and accuracy. In: Designing Clinical Research: An Epidemiologic Approach. Hulley SB, Cummings SR, eds. Philadelphia: Lippincott; 2001:37.Google Scholar
  14. 14.
    Leape LL, Bates DW, Cullen DJ. Systems analysis of adverse drug events. ADE prevention study. JAMA. 1995;274:35–43.PubMedCrossRefGoogle Scholar
  15. 15.
    Perrow C. Normal Accidents: Living With High Risk Technologies. New York: Basic Books; 1984.Google Scholar
  16. 16.
    Gordon L. Gordon’s Guide to the Surgical Morbidity and Mortality Conference. Philadelphia: Hanley and Belfus; 1994.Google Scholar
  17. 17.
    Accreditation Council for Graduate Medical Education. Essentials and Information Items. Graduate Medical Education Directory. Chicago Ill: American Medical Association; 1995.Google Scholar
  18. 18.
    Harbison S, Regehr G. Faculty and resident opinions regarding the role of Morbidity and Mortality Conference. Am J Surg 1999;177:136–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med. 1983;308:1000–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Cameron HM, McGoogan E. A prospective study of 1152 hospital autopsies. I: inaccuracies in death certification. J Pathol. 1981;133:273–83.PubMedCrossRefGoogle Scholar
  21. 21.
    Anderson RE, Hill RB, Key CR. The sensitivity and specificity of clinical diagnostics during five decades: toward an understanding of necessary fallibility. JAMA. 1989;261:1610–17.PubMedCrossRefGoogle Scholar
  22. 22.
    Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology. Boston: Little Brown, and Company; 1991.Google Scholar
  23. 23.
    Fischoff B. Hindsight does not equal foresight: the effect of outcome knowledge on judgment under uncertainty. J Exp Psychol Hum Percept Perform. 1975;1:288–99.CrossRefGoogle Scholar
  24. 24.
    Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care. JAMA. 1991;265:1957–60.PubMedCrossRefGoogle Scholar
  25. 25.
    Cheney FW, Posner K, Caplan RA, Ward RJ. Standard of care and anesthesia liability. JAMA. 1989;261:1599–1603.PubMedCrossRefGoogle Scholar
  26. 26.
    Rolph JE, Kravitz RL, McGuigan K. Malpractice claims data as a quality improvement tool. II. Is targeting effective? JAMA. 1991;266:2093–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Weiler PC. Medical Malpractice on Trial. Cambridge, Mass: Harvard University Press; 1991.Google Scholar
  28. 28.
    Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA. 1986;256:1017–20.PubMedCrossRefGoogle Scholar
  29. 29.
    Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320:759–63.PubMedCrossRefGoogle Scholar
  30. 30.
    Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross-sectional surveys. BMJ. 2000;320:745–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Brennan TA, Lee TH, O’Neil AC, Petersen LA. Integrating providers into quality improvement: a pilot project at one hospital. Qual Manag Health Care. 1992;1:29–35.PubMedCrossRefGoogle Scholar
  32. 32.
    Edmonson AC. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. J Appl Behav Sci. 1996;32:5–28.CrossRefGoogle Scholar
  33. 33.
    O’Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. A comparison of physicians self-reporting to medical record review to identify medical adverse events. Ann Intern Med. 1993;119:370–6.PubMedGoogle Scholar
  34. 34.
    Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does house staff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866–72.PubMedGoogle Scholar
  35. 35.
    Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77–87.PubMedGoogle Scholar
  36. 36.
    Iezzoni LI. Assessing quality using administrative data. Ann Intern Med. 1997;127:666–74.PubMedGoogle Scholar
  37. 37.
    Iezzoni LI. Identifying complications of care using administrative data. Med Care. 1994;32:700–15.PubMedCrossRefGoogle Scholar
  38. 38.
    Iezzoni LI, Davis RB, Palmer RH, et al. Does the Complications Screening Program flag cases with process of care problems? Using explicit criteria to judge processes. Int J Qual Health Care. 1999;11:107–18.PubMedCrossRefGoogle Scholar
  39. 39.
    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.PubMedCrossRefGoogle Scholar
  40. 40.
    Bates DW, O’Neil AC, Petersen LA, Lee TH, Brennan TA. Evaluation of screening criteria for adverse events in medical patients. Med Care. 1995;33:452–62.PubMedCrossRefGoogle Scholar
  41. 41.
    Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence care in hospitalized patients. N Engl J Med. 1991;324:370–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Ashton CM, Kuykendall DH, Johnson ML, Wray NP. An empirical assessment of the validity of explicit and implicit process of care criteria for quality assessment. Med Care. 1999;37:798–808.PubMedCrossRefGoogle Scholar
  43. 43.
    Localio AR, Lawthers A, Brennan TA. Identifying adverse events caused by medical care: degree of physician agreement in retrospective chart review. Ann Intern Med. 1996;125:457–64.PubMedGoogle Scholar
  44. 44.
    Luck J, Peabody JW, Dresselhaus TR, Lee M, Glassman P. How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record. Am J Med. 2000;108:642–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266:2847–51.PubMedCrossRefGoogle Scholar
  46. 46.
    Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison to chart-review and stimulated voluntary report. J Am Med Inform Assoc. 1998;5:305–14.PubMedGoogle Scholar
  47. 47.
    Helmreich RL, Schaefer HG. Team performance in the operating room. In: Bogner MS, ed. Human Error in Medicine. Hillsdale NJ: Lawrence Erlbaum Associates; 1994:225–53.Google Scholar
  48. 48.
    Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294–300.PubMedCrossRefGoogle Scholar
  49. 49.
    Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet. 1997;349:309–13.PubMedCrossRefGoogle Scholar
  50. 50.
    Barker KN. Data collection techniques: observation. Am J Hosp Pharm. 1980;37:1235–43.PubMedGoogle Scholar
  51. 51.
    Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. In: Bogner MS, ed. Human Error in Medicine. Hillsdale NJ: Lawrence Erlbaum Associates; 1994.Google Scholar
  52. 52.
    Last JM. A Dictionary of Epidemiology. New York: Oxford University Press; 1995.Google Scholar
  53. 53.
    Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med. 1995;333:1750–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–9.PubMedGoogle Scholar
  55. 55.
    Gaynes RP, Horan TC. Surveillance of nosocomial infections. In: Mayhall GC, ed, Hospital Epidemiology and Infection Control. Philidelphia: Lippincott Williams and Wilkins; 1999.Google Scholar

Copyright information

© Society of General Internal Medicine 2003

Authors and Affiliations

  1. 1.The Center for Clinical Research and Evidence Based Medicine, Division of General Medicine, Department of MedicineThe University of Texas Houston Medical SchoolHouston
  2. 2.the Houston Center for Quality of Care and Utilization Studies, a Health Services Research and Development Center of Excellence, Houston VA Medical Center, and Section for Health Services ResearchBaylor College of MedicineHouston

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