PURPOSE: Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors.
SUBJECTS: We conducted a prospective cohort study of 228 adult inpatients on a medicine unit of a Boston teaching hospital.
METHODS: Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone 10 days after discharge about “problems,” “mistakes,” and “injuries” that occurred. Physician investigators classified patients’ reports. We calculated event rates and used multivariable Poisson regression models to examine the factors associated with patient-reported events.
RESULTS: Of 264 eligible patients, 228 (86%) agreed to participate and completed 528 interviews. Seventeen patients (8%) experienced 20 adverse events; 1 was serious. Eight patients (4%) experienced 13 near misses; 5 were serious or life threatening. Eleven (55%) of 20 adverse events and 4 (31%) of 13 near misses were documented in the medical record, but none were found in the hospital incident reporting system. Patients with 3 or more drug allergies were more likely to report errors compared with patients without drug allergies (incidence rate ratio 4.7, 95% CI 1.7, 13.4).
CONCLUSIONS: Inpatients can identify adverse events affecting their care. Many patient-identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.
medical error adverse event patient participation incident reporting
Institute for Family-Centered Care. Your Role in Safe Medication Use. Boston, Mass: Massachusetts Coalition for the Prevention of Medical Errors; 1999. Available at: http://www.macoalition.org/documents/Best_Practice_Medication_Errors.pdf. Accessed December 14, 2003.Google Scholar
American Hospital Association. Successful practices for improving medication safety, 1999. Available at: http://www.hospitalconnect.com/aha/key_issues/medication_safety/ahainitiative/medicalsafety20015.html. Accessed December 14, 2004.Google Scholar
National Patient Safety Foundation. You can help improve patient safety. Available at: http://www.npsf.org/html/patients.html. Accessed January 20, 2003.Google Scholar
National Patient Safety Foundation. National Agenda for Action: Patients and Families in Patient Safety, 2003. Available at: http://www.npsf.org/download/AgendaFamilies.pdf. Accessed December 14, 2003.Google Scholar
Agency for Healthcare Research and Quality. 20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38. Rockville, Md: Agency for Healthcare Research and Quality; 2000. Available at: http://www.ahrq.gov/consumer/20tips.htm. Accessed December 14, 2003.Google Scholar
Davies RD, Ware JE. Involving consumers in quality of care assessment. Health Affairs. 1998;33–48.Google Scholar
Cleary PD, Edgman-Levitan S, Roberts M, et al. Patients evaluate their hospital care: a national survey. Health Affairs. 1991;11:254–67.CrossRefGoogle Scholar
Cleary PD. A hospitalization from hell: a patient’s perspective on quality. Ann Intern Med. 2003;138:33–9.PubMedGoogle Scholar
Public opinion of patient safety issues: research findings. Report prepared by Louis Harris and Associates for the National Patient Safety Foundation at the AMA. Chicago, Ill: National Patient Safety Foundation, 1997. Available at: http://www.npsf.org/download/1997survey.pdf. Accessed December 14, 2003.Google Scholar
How safe is your hospital? Consumer reports readers rate the care they or a relative received. Consumer Rep. 2002;68:12–8.Google Scholar
Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933–40.PubMedCrossRefGoogle Scholar
Gandhi TK, Weingart SN, Peterson J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556–64.PubMedCrossRefGoogle Scholar
Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996;335:1963–7.PubMedCrossRefGoogle Scholar
Studdert DM, Thomas EJ, Burstin HR, Zbar BI, Orav EJ, Brennan TA. Negligent care and malpractice claiming behavior in Utah and Colorado. Med Care. 2000;38:250–60.PubMedCrossRefGoogle Scholar
Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2000;15:470–7.PubMedCrossRefGoogle Scholar
Weingart SN, Callanan LD, Ship AN, Aronson MD. A physician-based voluntary reporting system for adverse events and medical errors. J Gen Intern Med. 2001;16:809–14.PubMedCrossRefGoogle Scholar
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161–7.PubMedGoogle Scholar
Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646–51.PubMedCrossRefGoogle Scholar
Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274:29–34.PubMedCrossRefGoogle Scholar
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med. 1991;324:370–76.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322:517–9.PubMedCrossRefGoogle Scholar
Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust. 1995;163:458–71.PubMedGoogle Scholar
Thomas EJ, Studdert DM, Runciman WB, et al. A comparison of iatrogenic injury studies in Australia and the USA: context, methods, casemix, population, patient and hospital characteristics. Int J Qual Health Care. 2000;12:371–8.PubMedCrossRefGoogle Scholar
Runciman WB, Webb RK, Helps SC, et al. A comparison of iatrogenic injury studies in Australia and the USA: reviewer behaviour and quality of care. Int J Qual Health Care. 2000;12:379–88.PubMedCrossRefGoogle Scholar
Pizzi LT, Goldfarb NI, Nash DB. Other practices related to patient participation. Ch. 50. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No. 43. Rockville, Md: US Agency for Healthcare Research and Quality; 2001:575–8.Google Scholar
O’Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993;119:370–6.PubMedGoogle Scholar
Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc. 1998;5:305–14.PubMedGoogle Scholar
Field TS, Gurwitz JH, Avorn J, et al. Risk factors for adverse drug events among nursing home residents. Arch Intern Med. 2001;161:1629–34.PubMedCrossRefGoogle Scholar
Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA. 2003;290:1899–905.PubMedCrossRefGoogle Scholar