PMID- 20692071
OWN - NLM
STAT- MEDLINE
DCOM- 20110225
LR  - 20101116
IS  - 1532-2939 (Electronic)
IS  - 0195-6701 (Linking)
VI  - 76
IP  - 4
DP  - 2010 Dec
TI  - Limiting risk of hospital adverse events: avoiding train wrecks is more important 
      than counting and reporting them.
PG  - 283-6
LID - 10.1016/j.jhin.2010.06.010 [doi]
AB  - Targets implemented at national or state levels have been employed in response to 
      excessive numbers of adverse events (AEs) such as multiple antibiotic-resistant 
      Staphylococcus aureus bacteraemias. Hospital resources are limited and setting 
      such targets can result in resource diversion to dealing with the targeted AEs. 
      There may be initial success as judged by decreasing counts but underlying 
      problems are not necessarily addressed, and there is evidence that other 
      non-targeted AEs may increase. Moreover, the values of individual observations 
      can be greatly influenced by random variation. This can make it difficult using 
      comparisons and targets to draw conclusions about the work of an institution. 
      Although counting AEs is essential, the key to avoiding episodes of patient harm 
      is prevention. This requires the implementation of evidence-based systems. These 
      are already available for many AEs in the form of 'bundles' and checklists. When 
      these systems are properly implemented and sustained, AE rates tend to occur at 
      minimum predictable levels. Unfortunately, in spite of widespread knowledge and 
      aggressive promotion, high levels of compliance have often been difficult to 
      achieve and sustain. Better understanding and implementation of methods to 
      sustain evidence-based systems are needed. Checklists, used as part of an overall 
      system involving leadership and empowerment, application of evidence, culture 
      change and measurement, may help to overcome this problem.
CI  - Copyright (c) 2010 The Hospital Infection Society. Published by Elsevier Ltd. All 
      rights reserved.
FAU - Morton, A
AU  - Morton A
AD  - Infection Management Services, Princess Alexandra Hospital, Brisbane, Queensland, 
      Australia. amor5444@bigpond.net.au
FAU - Cook, D
AU  - Cook D
FAU - Mengersen, K
AU  - Mengersen K
FAU - Waterhouse, M
AU  - Waterhouse M
LA  - eng
PT  - Journal Article
PT  - Review
DEP - 20100809
PL  - England
TA  - J Hosp Infect
JT  - The Journal of hospital infection
JID - 8007166
SB  - IM
MH  - Cross Infection/*epidemiology/*prevention & control
MH  - Humans
MH  - Infection Control/*methods
MH  - Risk Management/*methods
MH  - Sentinel Surveillance
EDAT- 2010/08/10 06:00
MHDA- 2011/02/26 06:00
CRDT- 2010/08/10 06:00
PHST- 2010/01/22 00:00 [received]
PHST- 2010/06/18 00:00 [accepted]
PHST- 2010/08/10 06:00 [entrez]
PHST- 2010/08/10 06:00 [pubmed]
PHST- 2011/02/26 06:00 [medline]
AID - S0195-6701(10)00288-4 [pii]
AID - 10.1016/j.jhin.2010.06.010 [doi]
PST - ppublish
SO  - J Hosp Infect. 2010 Dec;76(4):283-6. doi: 10.1016/j.jhin.2010.06.010. Epub 2010 
      Aug 9.