Royal College of Surgeons in Ireland
Browse
- No file added yet -

Adverse Events in Healthcare: learning from mistakes

Download (567.21 kB)
Version 2 2022-04-04, 11:36
Version 1 2019-11-22, 15:41
journal contribution
posted on 2022-04-04, 11:36 authored by Natasha RafterNatasha Rafter, Anne HickeyAnne Hickey, Sarah Condell, Ronan ConroyRonan Conroy, P O'Connor, D Vaughan, David WilliamsDavid Williams

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 hospitalisation, 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 aims to discuss the need for a safety culture that can learn from adverse events, describe ways to measure adverse events, and comment on why current adverse event monitoring is unable to demonstrate trends in patient safety.

Funding

Health Research Board of Ireland, INAES/2013/1.

History

Comments

This is a pre-copyedited, author-produced PDF of an article accepted for publication in QJM: An International Journal of Medicine following peer review. The version of record Rafter N, Hickey A, Condell S, Conroy R, O'Connor P, Vaughan D, Williams D. Adverse Events in Healthcare: learning from mistakes. Quarterly Journal of Medicine. First published online: 30 July 2014 is available at: http://qjmed.oxfordjournals.org/content/early/2014/08/09/qjmed.hcu145.

Published Citation

Rafter N, Hickey A, Condell S, Conroy R, O'Connor P, Vaughan D, Williams D. Adverse Events in Healthcare: learning from mistakes. Quarterly Journal of Medicine. First published online: 30 July 2014.

Publication Date

2014-01-01

PubMed ID

25078411

Department/Unit

  • Data Science Centre
  • Health Psychology
  • Medicine
  • Public Health and Epidemiology

Usage metrics

    Royal College of Surgeons in Ireland

    Exports

    RefWorks
    BibTeX
    Ref. manager
    Endnote
    DataCite
    NLM
    DC