Hospital patients' reports of medical errors and undesirable events in their health care.

OBJECTIVE: To investigate hospital patients' reports of undesirable events in their health care. DESIGN: Cross-sectional mixed methods design. PARTICIPANTS: A total of 80 medical and surgical patients (mean age 58, 56 male). INTERVENTION: Patients were interviewed post-discharge using a survey to assess patient reports of errors or problems in their care. Patients' medical records and notes were also reviewed. MAIN OUTCOME MEASURES: Frequency of health care process problems, medical complications and interpersonal problems, and patient willingness to report an undesirable event in their care. RESULTS: In total, 258 undesirable events were reported (rate of 3.2 per person), including 136 interpersonal problems, 90 medical complications and 32 health care process problems. Patients identified a number of events that were reported in the medical records (30 out of 36). In addition, patients reported events that were not recorded in the medical records. Patients were more willing (P < 0.05) to report undesirable events to a researcher (as in the present case) than to a local or national reporting system. CONCLUSION: Patients appear able to report undesirable events that occur in their health care management over and above those that are recorded in their medical records. However, patients appear more willing to report these incidents for the purpose of a study rather than to an established incident reporting system. Interventions aimed at educating and encouraging patients about incident reporting systems need to be developed in order to enhance this important contribution patients could make to improving patient safety.

Junior doctors' reflections on patient safety.

AIM: To determine whether foundation year 1 (FY1) doctors reflect upon patient safety incidents (PSIs) within their portfolios and the potential value of such reflections for quality of care. METHODS: A cross-sectional retrospective review of every 'reflective practice' portfolio entry made by all FY1 doctors within an Acute Teaching Hospital Trust was conducted in February 2010. Entries were reviewed by two independent blinded researchers to determine whether they related to a PSI that is, any unintended or unexpected incident that could have or did lead to patient harm. For all entries rated positive by both reviewers, a content analysis approach was used to code PSI into incident type, contributing factors and patient outcome according to validated frameworks developed by the National Patient Safety Agency. RESULTS: 139 reflective practice entries were completed by 30 trainees (15 men, 15 women, mean age 24 years). Of the 139 entries, 49% reflected on a PSI. Of these, 22% were due to errors in clinical assessment; 22% were due to delayed access to care; 18% were due to infrastructure/staffing deficiencies; and 16% were due to medication errors. The most common contributing factors were team/social factors (23%), patient factors (22%), communication and task factors (both 17%). The majority of PSIs led to no harm. Six entries described PSIs resulting in patient death, the majority of which were attributable to diagnostic errors. CONCLUSIONS: FY1 doctors commonly reflect on PSIs within their professional portfolios. Such critical reflection can encourage learning but may also promote patient safety and the quality of healthcare across all medical specialties.

The problem of engaging hospital doctors in promoting safety and quality in clinical care.

There is widespread agreement that the medical profession has much to learn about addressing adverse events in clinical practice and participating in clinical governance. In England and Wales centrally driven initiatives such as medical audit, clinical governance and the National Reporting and Learning System have failed to transform the management of iatrogenic adverse events. In this article we explore the historical and cultural background of these issues with respect to hospital medicine and suggest means of tackling the challenges ahead.

Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.

BACKGROUND: Over the past five years, in most hospitals in England and Wales, incident reporting has become well established but it remains unclear how well reports match clinical adverse events. International epidemiological studies of adverse events are based on retrospective, multi-hospital case record review. In this paper the authors describe the use of incident reporting, pharmacist surveillance and local real-time record review for the recognition of clinical risks associated with hospital inpatient care. METHODOLOGY: Data on adverse events were collected prospectively on 288 patients discharged from adult acute medical and surgical units in an NHS district general hospital using incident reports, active surveillance of prescription charts by pharmacists and record review at time of discharge. RESULTS: Record review detected 26 adverse events (AEs) and 40 potential adverse events (PAEs) occurring during the index admission. In contrast, in the same patient group, incident reporting detected 11 PAEs and no AEs. Pharmacy surveillance found 10 medication errors all of which were PAEs. There was little overlap in the nature of events detected by the three methods. CONCLUSION: The findings suggest that incident reporting does not provide an adequate assessment of clinical adverse events and that this method needs to be supplemented with other more systematic forms of data collection. Structured record review, carried out by clinicians, provides an important component of an integrated approach to identifying risk in the context of developing a safety and quality improvement programme.

Learning from litigation. The role of claims analysis in patient safety.

Claims for malpractice and medical negligence are a potentially important source of information on the causes of harm to patients and have provided valuable lessons in the past. However today, with many additional sources of information and methods of analysis, the role of claims analysis needs to be reappraised. We consider the role of claims analysis in relation to other methods of studying adverse outcomes, review previous studies of claims and summarize the findings of four recent British specialty claims reviews. Claims analysis has a number of inherent limitations. We suggest that there is now no case for ad hoc claims reviews which rely on data that have been assembled for legal purposes only. Claims review is still potentially useful for rare events or in cases where other sources of data are not available. However, future claims reviews need to meet basic criteria before being undertaken; these include prospective identification of the relevant questions and variables, adequacy and completeness of the data set, availability of expert reviewers and clear protocols for review.