PMID- 19734322
OWN - NLM
STAT- MEDLINE
DCOM- 20100115
LR  - 20091105
IS  - 1555-824X (Electronic)
IS  - 1062-8606 (Linking)
VI  - 24
IP  - 6
DP  - 2009 Nov-Dec
TI  - Injury and death associated with incidents reported to the patient safety net.
PG  - 520-4
LID - 10.1177/1062860609345788 [doi]
AB  - 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.
FAU - Reid, Mark
AU  - Reid M
AD  - Department of Medicine, Denver Health, Denver, Colorado 80204-4507, USA. 
      Mark.Reid@dhha.org
FAU - Estacio, Raymond
AU  - Estacio R
FAU - Albert, Rick
AU  - Albert R
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
DEP - 20090904
PL  - Netherlands
TA  - Am J Med Qual
JT  - American journal of medical quality : the official journal of the American 
      College of Medical Quality
JID - 9300756
SB  - IM
MH  - Colorado
MH  - Hospitals/standards/statistics & numerical data
MH  - Humans
MH  - Medical Errors/classification/mortality/*statistics & numerical data
MH  - Medication Errors/mortality/statistics & numerical data
MH  - Retrospective Studies
MH  - Risk Management/*statistics & numerical data
EDAT- 2009/09/08 06:00
MHDA- 2010/01/16 06:00
CRDT- 2009/09/08 06:00
PHST- 2009/09/08 06:00 [entrez]
PHST- 2009/09/08 06:00 [pubmed]
PHST- 2010/01/16 06:00 [medline]
AID - 1062860609345788 [pii]
AID - 10.1177/1062860609345788 [doi]
PST - ppublish
SO  - Am J Med Qual. 2009 Nov-Dec;24(6):520-4. doi: 10.1177/1062860609345788. Epub 2009 
      Sep 4.