This Article Full Text (PDF) All Versions of this Article: 1062860609345788v1 24/6/520    most recent References Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Scopus Google Scholar Articles by Reid, M. Articles by Albert, R. PubMed PubMed Citation Articles by Reid, M. Articles by Albert, R. Social Bookmarking                         What's this?

Injury and Death Associated With Incidents Reported to the Patient Safety Net

Department of Medicine, Denver Health, and Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado, Mark.Reid{at}dhha.org

Raymond Estacio, MD

Department of Community Health, Denver Health, and Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado

Rick Albert, MD

Department of Medicine, Denver Health, and Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado

The authors retrospectively evaluated anonymously submitted inpatient medical error reports from 8 institutions participating in the University HealthSystem Consortium Patient Safety Net (PSN) in 2004 in an attempt to focus patient safety efforts on problems that were most commonly associated with harm. Of the 25 300 incidents reported, 3381 (13.3%) were associated with adverse events (AEs), and 109 (0.4%) were associated with death. Although the most commonly reported categories of incidents associated with AEs were complications of procedure/treatment/test (29%), falls (17%), and medication errors (10%), the taxonomy of the PSN limited efforts to find specific errors in care that might be addressed by attempts to improve patient safety. Skin breakdown and falls were confirmed as presenting substantial risks to hospitalized patients, in that 59% of the incidents reported in the skin integrity category and 22% of falls resulted in AEs. The benefits and limitations of a voluntary reporting system are discussed.

Key Words: medical errors • patient safety • Patient Safety Net • error reporting

This version was published on November 1, 2009

American Journal of Medical Quality, Vol. 24, No. 6, 520-524 (2009)
DOI: 10.1177/1062860609345788


CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter    What's this?