PMID- 20142403
OWN - NLM
STAT- MEDLINE
DCOM- 20110204
LR  - 20220410
IS  - 1475-3901 (Electronic)
IS  - 1475-3898 (Linking)
VI  - 19
IP  - 5
DP  - 2010 Oct
TI  - Exploring the causes of adverse events in hospitals and potential prevention 
      strategies.
PG  - e5
LID - 10.1136/qshc.2008.030726 [doi]
AB  - OBJECTIVES: To examine the causes of adverse events (AEs) and potential 
      prevention strategies to minimise the occurrence of AEs in hospitalised patients. 
      METHODS: For the 744 AEs identified in the patient record review study in 21 
      Dutch hospitals, trained reviewers were asked to select all causal factors that 
      contributed to the AE. The results were analysed together with data on 
      preventability and consequences of AEs. In addition, the reviewers selected one 
      or more prevention strategies for each preventable AE. The recommended prevention 
      strategies were analysed together with four general causal categories: technical, 
      human, organisational and patient-related factors. RESULTS: Human causes were 
      predominantly involved in the causation of AEs (in 61% of the AEs), 61% of those 
      being preventable and 13% leading to permanent disability. In 39% of the AEs, 
      patient-related factors were involved, in 14% organisational factors and in 4% 
      technical factors. Organisational causes contributed relatively often to 
      preventable AEs (93%) and AEs resulting in permanent disability (20%). 
      Recommended strategies to prevent AEs were quality assurance/peer review, 
      evaluation of safety behaviour, training and procedures. For the AEs with human 
      and patient-related causes, reviewers predominantly recommended quality 
      assurance/peer review. AEs caused by organisational factors were considered 
      preventable by improving procedures. DISCUSSION: Healthcare interventions 
      directed at human causes are recommended because these play a large role in AE 
      causation. In addition, it seems worthwhile to direct interventions on 
      organisational causes because the AEs they cause are nearly always believed to be 
      preventable. Organisational factors are thus relatively easy to tackle. Future 
      research designs should allow researchers to interview healthcare providers that 
      were involved in the event, as an additional source of information on 
      contributing factors.
FAU - Smits, M
AU  - Smits M
AD  - NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN 
      Utrecht, The Netherlands. m.smits@nivel.nl
FAU - Zegers, M
AU  - Zegers M
FAU - Groenewegen, P P
AU  - Groenewegen PP
FAU - Timmermans, D R M
AU  - Timmermans DR
FAU - Zwaan, L
AU  - Zwaan L
FAU - van der Wal, G
AU  - van der Wal G
FAU - Wagner, C
AU  - Wagner C
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
DEP - 20100208
PL  - England
TA  - Qual Saf Health Care
JT  - Quality & safety in health care
JID - 101136980
MH  - *Causality
MH  - *Hospitals
MH  - Humans
MH  - Medical Audit
MH  - Medical Errors/*prevention & control
MH  - Netherlands
MH  - *Risk Management
EDAT- 2010/02/10 06:00
MHDA- 2011/02/05 06:00
CRDT- 2010/02/10 06:00
PHST- 2010/02/10 06:00 [entrez]
PHST- 2010/02/10 06:00 [pubmed]
PHST- 2011/02/05 06:00 [medline]
AID - qshc.2008.030726 [pii]
AID - 10.1136/qshc.2008.030726 [doi]
PST - ppublish
SO  - Qual Saf Health Care. 2010 Oct;19(5):e5. doi: 10.1136/qshc.2008.030726. Epub 2010 
      Feb 8.