What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents
Journal of General Internal MedicinePublished 19 August 2005Open access
Saul N. Weingart, Odelya E. Pagovich, Daniel Z. Sands, Joseph M. Li, Mark D. Aronson, Roger B. Davis
Citations332
SJR quartileQ1
SJR score1.99
SNIP1.71
Generate an AI Snapshot to get a quick, structured summary of this paper.
Study Snapshot
ObjectiveStudy objective
MethodsResearch methodology
PopulationPopulation studied
Sample sizeSample sizes
OutcomesStudy outcomes here
ResultsStudy results comes here
LimitationsResearch study limitations comes here
A concise AI-generated summary of the paper will appear here once you click Generate AI Snapshot.
TL;DR
Engaging hospital inpatients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.
Abstract
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.
Keywords
MedicineHealth Professions
New England Journal of MedicineIncidence of Adverse Events and Negligence in Hospitalized Patients
4,666 Citations1991Troyen A. Brennan, Lucian L. Leape +7 more
The incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care, in New York State in 1984 were estimated.
JAMAIncidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group
2,509 Citations1995David W. Bates
Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable and prevention strategies should target both stages of the drug delivery process.
The Medical Journal of AustraliaThe Quality in Australian Health Care Study
2,397 Citations1995R. M. Wilson, W. B. Runciman +4 more
JAMAIncidence of Adverse Drug Events and Potential Adverse Drug Events
2,118 Citations1995David W. Bates
Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable and prevention strategies should target both stages of the drug delivery process.
BMJAdverse events in British hospitals: preliminary retrospective record review
2,074 Citations2001Charles Vincent, Graham Neale +1 more
These results suggest that adverse events are a serious source of harm to patients and a large drain on NHS resources.
Annals of Internal MedicineThe Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital
1,908 Citations2003Alan J. Forster, Harvey J. Murff +3 more
The incidence and severity of adverse events affecting patients after discharge from the hospital to home were determined and two board-certified internists independently reviewed to determine whether medical management caused an injury and, if so, whether it was preventable or ameliorable.
Medical CareIncidence and Types of Adverse Events and Negligent Care in Utah and Colorado
1,671 Citations2000Eric J. Thomas, David M. Studdert +7 more
The incidence and types of adverse events in Utah and Colorado in 1992 were similar to those in New York State in 1984 and improving systems of surgical care and drug delivery could substantially reduce the burden of iatrogenic injury.
PubMedMaking health care safer: a critical analysis of patient safety practices.
1,630 Citations2001Kaveh G Shojania, Ben Duncan +3 more
This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety and identify practices with the strongest supporting evidence that decrease the risks associated with hospitalization, critical care, or surgery.
New England Journal of MedicineAdverse Drug Events in Ambulatory Care
1,345 Citations2003Tejal K. Gandhi, Saul N. Weingart +9 more
Improving communication between outpatients and providers may help prevent adverse events related to drugs, and many are preventable or ameliorable.
PubMedIncidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group.
1,109 Citations1995D W Bates, Cullen Dj +8 more
BMJ Quality & SafetyIncidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I
943 Citations2004Troyen A. Brennan
There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.
Journal of General Internal MedicineMedical errors related to discontinuity of care from an inpatient to an outpatient setting
798 Citations2003Carlton Moore, Juan P. Wisnivesky +2 more
The prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.
New England Journal of MedicineViews of Practicing Physicians and the Public on Medical Errors
774 Citations2002Robert J. Blendon, Catherine M. DesRoches +8 more
Though substantial proportions of the public and practicing physicians report that they have had personal experience with medical errors, neither group has the sense of urgency expressed by many national organizations to advance their agenda.
JAMASafety of Patients Isolated for Infection Control
570 Citations2003Henry T. Stelfox
Compared with controls, patients isolated for infection control precautions experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care.
International Journal of Trauma NursingIncidence of adverse drug events and potential adverse drug events
538 Citations1995D. W. Bates, David J. Cullen +1 more
Journal of the American Medical Informatics AssociationIdentifying Adverse Drug Events: Development of a Computer-based Monitor and Comparison with Chart Review and Stimulated Voluntary Report
517 Citations1998Ashish K. Jha, Gilad J. Kuperman +8 more
The computer-based monitoring system represents an efficient approach for measuring ADE frequency and gauging the effectiveness of ADE prevention programs and overlapped with two other ADE detection strategies, suggesting that the incidence of ADEs may be higher than previously reported and that different detection methods capture different events.
Archives of Internal MedicineRisk Factors for Adverse Drug Events Among Nursing Home Residents
407 Citations2001Terry S. Field, Jerry H. Gurwitz +6 more
It is possible to identify nursing home residents at high risk of having an ADE, and particular attention should be directed at new residents, those with multiple medical conditions, those taking multiple medications, and those taking psychoactive medications, opioids, or anti-infective drugs.
New England Journal of MedicineRelation between Negligent Adverse Events and the Outcomes of Medical-Malpractice Litigation
353 Citations1996Troyen A. Brennan, Colin M. Sox +1 more
The severity of the patient's disability, not the occurrence of an adverse event or an adverseevent due to negligence, was predictive of payment to the plaintiff among the malpractice claims studied.
Journal of Patient SafetyNational Patient Safety Foundation
351 Citations2007Diane C. Pinakiewicz
The National Patient Safety Foundation's 10-year anniversary theme, Patient Safety - A Road Taken Together, embodies the deep commitment to the collaboration and partnering that is integral to this work and honors the ongoing nature of the collective efforts.
Medical CareNegligent Care and Malpractice Claiming Behavior in Utah and Colorado
329 Citations2000David M. Studdert, Eric J. Thomas +4 more
The elderly and the poor are particularly likely to be among those who suffer negligence and do not sue, perhaps because their socioeconomic status inhibits opportunities to secure legal representation.
Annals of Internal MedicinePhysician Reporting Compared with Medical-Record Review to Identify Adverse Medical Events
318 Citations1993Anne O’Neil, Laura A. Petersen +4 more
This study compared physician reporting of adverse events by the housestaff on the medical service of a teaching hospital with a retrospective two-step screening of the medical record for adverse events followed by implicit physician judgment about identified events and compared the combined strategies with the quality-of-care data routinely collected by the hospital.
Health AffairsInvolving Consumers in Quality of Care Assessment
295 Citations1988Allyson Ross Davies, John E. Ware
The authors conclude that consumers can provide a valid assessment of quality and that bias from personal characteristics is not strong enough to undermine that assessment.
JAMAService Quality in Health Care
257 Citations1999John W. Kenagy
This article illustrates service quality principles by analyzing a routine encounter in health care from a service quality point of view and concludes that if high-quality service had a greater presence in practices and institutions, it would improve clinical outcomes and patient and physician satisfaction while reducing cost.
JAMAHealth Care Quality
233 Citations1997Paul D. Cleary
The needs, challenges, and potential action steps for increasing the prominence of the user's perspective in 3 areas are discussed: the conceptualization and definition of quality; the measurement ofquality; and the routine quality assessment and improvement.
PubMedHealth care quality. Incorporating consumer perspectives.
166 Citations1997Paul D. Cleary, Susan Edgman‐Levitan
International Journal for Quality in Health CareA comparison of iatrogenic injury studies in Australia and the USA I: context, methods, casemix, population, patient and hospital characteristics
161 Citations2000E. J THOMAS
Five methodological differences accounted for some of the discrepancy between the two studies and the remaining three-fold disparity are that quality of care was worse in Australia and that medical record content and/or reviewer behaviour was different.
International Journal for Quality in Health CareA comparison of iatrogenic injury studies in Australia and the USA II: reviewer behaviour and quality of care
119 Citations2000W. B. Runciman
It is hypothesize that this disparity is due to different thresholds for admission and discharge and to a greater degree of under-reporting of certain types of problems as AEs by UTCOS than QAHCS reviewers.
Journal of General Internal MedicineConfidential clinician-reported surveillance of adverse events among medical inpatients
99 Citations2000Saul N. Weingart, Amy N. Ship +1 more
House officers detect many AEs among inpatients, and confidential peer interviews of front-line providers is a promising method for identifying medical errors and substandard quality.
Journal of General Internal MedicineA physician-based voluntary reporting system for adverse events and medical errors
96 Citations2001Saul N. Weingart, Lawrence D. Callanan +2 more
A physician-based voluntary reporting system for medical errors is feasible and acceptable to front-line clinicians and agreed that it could be implemented on a regular basis.
Annals of Internal MedicineA Hospitalization from Hell: A Patient's Perspective on Quality
87 Citations2003Paul D. Cleary
The patient, Mr. Q, was admitted to a university hospital for ankle arthrodesis due to severe hemophilia-related arthritis and was scheduled for surgery at a time when a hematology nurse was not available, indicating a lack of coordination that could have had an important effect on the outcome of his hospitalization.
JAMAA 40-Year-Old Woman Who Noticed a Medication Error
31 Citations2001David W. Bates
A 40-year-old woman who found an error with her prescribed medications and was able to continue her planned HIV regime uninterrupted and did not experience any harm from this event.