PMID- 19051661
OWN - NLM
STAT- MEDLINE
DCOM- 20090127
LR  - 20211020
IS  - 0036-9330 (Print)
IS  - 0036-9330 (Linking)
VI  - 53
IP  - 4
DP  - 2008 Nov
TI  - Detection of adverse events in a Scottish hospital using a consensus-based 
      methodology.
PG  - 26-30
AB  - OBJECTIVE: To determine, using a consensus based methodology, the rate and nature 
      of adverse events (AEs) among patients admitted to acute medicine, acute surgery 
      and obstetrics in a large teaching hospital in Scotland. METHODS: Retrospective 
      case-note review of 450 medical, nursing and medication records to identify and 
      classify adverse events. For 354 patients whose length of stay was greater than 
      24 hours, the overall adverse event rate was 7.9% which ranged from 0% in 
      obstetrics, 7.2% in acute medicine to 13% in acute surgery. Among all AEs, 43% 
      were deemed preventable by a consensus group and 59% of the AEs contributed to a 
      proportion of the patients' hospital stay or led to hospital readmission. Whilst 
      nurse identification of adverse events was highly specific (94%), its sensitivity 
      was poor (43%). Only 10% of the identified AEs were identified by the hospital's 
      voluntary reporting system for adverse events. The estimated additional cost of 
      adverse events in terms of bed days was l69,189 which if extrapolated 
      Scotland-wide could cost l297 million per annum. CONCLUSIONS: This study supports 
      the need to continue the traditional retrospective record review to identify 
      adverse events. The current hospital-based reporting of adverse events does not 
      provide a complete measure of adverse events and needs to be complemented by 
      other measures.
FAU - Williams, D J
AU  - Williams DJ
AD  - Department of Clinical Pharmacology, Ward 12, Aberdeen Royal Infirmary, 
      Foresterhill, Aberdeen AB25 2ZN. davidwilliams4@nhs.net
FAU - Olsen, S
AU  - Olsen S
FAU - Crichton, W
AU  - Crichton W
FAU - Witte, K
AU  - Witte K
FAU - Flin, R
AU  - Flin R
FAU - Ingram, J
AU  - Ingram J
FAU - Campbell, M K
AU  - Campbell MK
FAU - Watson, M
AU  - Watson M
FAU - Hopf, Y
AU  - Hopf Y
FAU - Cuthbertson, B H
AU  - Cuthbertson BH
LA  - eng
GR  - HSRU2/CSO_/Chief Scientist Office/United Kingdom
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
PL  - Scotland
TA  - Scott Med J
JT  - Scottish medical journal
JID - 2983335R
SB  - IM
MH  - Adult
MH  - *Consensus
MH  - Female
MH  - Hospitalization
MH  - Hospitals
MH  - Humans
MH  - Male
MH  - *Medical Audit
MH  - *Medical Errors
MH  - Medical Records
MH  - Middle Aged
MH  - Retrospective Studies
MH  - Scotland
EDAT- 2008/12/05 09:00
MHDA- 2009/01/28 09:00
CRDT- 2008/12/05 09:00
PHST- 2008/12/05 09:00 [pubmed]
PHST- 2009/01/28 09:00 [medline]
PHST- 2008/12/05 09:00 [entrez]
AID - 10.1258/RSMSMJ.53.4.26 [doi]
PST - ppublish
SO  - Scott Med J. 2008 Nov;53(4):26-30. doi: 10.1258/RSMSMJ.53.4.26.