PMID: 11903759Mar 21, 2002Paper

A physician-based voluntary reporting system for adverse events and medical errors

Journal of General Internal Medicine
Saul N WeingartM D Aronson

Abstract

To create a voluntary reporting method for identifying adverse events (AEs) and potential adverse events (PAEs) among medical inpatients. Medical house officers asked their peers about obstacles to care, injuries or extended hospitalizations, and problems with medications that affected their patients. Two independent reviewers coded event narratives for adverse outcomes, responsible parties, preventability, and process problems. We corroborated house officers' reports with hospital incident reports and conducted a retrospective chart review. The cardiac step-down, oncology, and medical intensive care units of an urban teaching hospital. Structured confidential interviews by postgraduate year-2 and -3 medical residents of interns during work rounds. Respondents reported 88 events over 3 months. AEs occurred among 5 patients (0.5% of admissions) and PAEs among 48 patients (4.9% of admissions). Delayed diagnoses and treatments figured prominently among PAEs (54%). Clinicians were responsible for the greatest number of incidents (55%), followed by workers in the laboratory (11%), radiology (15%), and pharmacy (3%). Respondents identified a variety of problematic processes of care, including problems with diagnosis (16%), therapy (2...Continue Reading

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