A comparison of hospital adverse events identified by three widely used detection methods

• Published in: International journal for quality in health care Vol. 21; no. 4; pp. 301 - 307
• Main Authors: Naessens, James M., Campbell, Claudia R., Huddleston, Jeanne M., Berg, Bjorn P., Lefante, John J., Williams, Arthur R., Culbertson, Richard A.
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01.08.2009
• Subjects: adverse events; Cross-Sectional Studies; Documentation; Hospital Administration - statistics & numerical data; Humans; Incidence; International Classification of Diseases - statistics & numerical data; Medical Errors - statistics & numerical data; patient safety; Quality Assurance, Health Care; Quality Indicators, Health Care - statistics & numerical data; quality measurement; reported events; Safety Management - statistics & numerical data; United States; United States Agency for Healthcare Research and Quality - statistics & numerical data; United States; Eire, Connaught, Mayo; USA, New York, Rochester; quality measurement; patient safety; adverse events; reported events
• ISSN: 1353-4505; 1464-3677
• DOI: 10.1093/intqhc/mzp027

Objective Determine the degree of congruence between several measures of adverse events. Design Cross-sectional study to assess frequency and type of adverse events identified using a variety of methods. Setting Mayo Clinic Rochester hospitals. Participants All inpatients discharged in 2005 (n = 60 599). Interventions Adverse events were identified through multiple methods: (i) Agency for Healthcare Research and Quality-defined patient safety indicators (PSIs) using ICD-9 diagnosis codes from administrative discharge abstracts, (ii) provider-reported events, and (iii) Institute for Healthcare Improvement Global Trigger Tool with physician confirmation. PSIs were adjusted to exclude patient conditions present at admission. Main outcome measure Agreement of identification between methods. Results About 4% (2401) of hospital discharges had an adverse event identified by at least one method. Around 38% (922) of identified events were provider-reported events. Nearly 43% of provider-reported adverse events were skin integrity events, 23% medication events, 21% falls, 1.8% equipment events and 37% miscellaneous events. Patients with adverse events identified by one method were not usually identified using another method. Only 97 (6.2%) of hospitalizations with a PSI also had a provider-reported event and only 10.5% of provider-reported events had a PSI. Conclusions Different detection methods identified different adverse events. Findings are consistent with studies that recommend combining approaches to measure patient safety for internal quality improvement. Potential reported adverse event inconsistencies, low association with documented harm and reporting differences across organizations, however, raise concerns about using these patient safety measures for public reporting and organizational performance comparison.