PMID- 30896559
OWN - NLM
STAT- MEDLINE
DCOM- 20211124
LR  - 20230928
IS  - 1549-8425 (Electronic)
IS  - 1549-8417 (Linking)
VI  - 17
IP  - 4
DP  - 2021 Jun 1
TI  - Examining Causes and Prevention Strategies of Adverse Events in Deceased Hospital 
      Patients: A Retrospective Patient Record Review Study in the Netherlands.
PG  - 282-289
LID - 10.1097/PTS.0000000000000586 [doi]
AB  - OBJECTIVE: To improve patient safety and possibly prevent mortality from adverse 
      events (AEs) in hospitals, it is important to gain insight in their underlying 
      causes. We aimed to examine root causes and potential prevention strategies of 
      AEs in deceased hospital patients. METHODS: Data on 571 AEs were used from two 
      retrospective patient record review studies of patients who died during 
      hospitalization in the Netherlands. Trained reviewers assessed contributing 
      factors and potential prevention strategies. The results were analyzed together 
      with data on preventability of the AE and the relationship of the AE with the 
      death of the patient. RESULTS: In 47% of the AEs, patient-related causes were 
      identified, in 35% human causes, in 9% organizational causes, and in 3% technical 
      causes. Preventable AEs were caused by technical, organizational, and human 
      causes (78%, 74%, and 74%, respectively) more often than by patient-related 
      causes (33%). In addition, technical factors caused AEs leading to preventable 
      death (78%) relatively often. Recommended strategies to prevent AEs were quality 
      assurance/peer review, evaluation of safety behavior, improving procedures, and 
      improving information and communication structures. CONCLUSIONS: Human failures 
      played an important role in the causation of AEs in Dutch hospitals, because they 
      occurred frequently and they were frequently the cause of preventable AEs. To a 
      lesser extent, latent organizational and technical factors were identified. 
      Patient-related factors were often identified, but the preventability of the AEs 
      with these causes was low. For future research into causes of AEs, we recommend 
      combining record review with interviewing.
CI  - Copyright (c) 2019 Wolters Kluwer Health, Inc. All rights reserved.
FAU - Smits, Marleen
AU  - Smits M
FAU - Langelaan, Maaike
AU  - Langelaan M
AD  - From the Nivel, Netherlands Institute for Health Services Research, Utrecht.
FAU - de Groot, Janke
AU  - de Groot J
AD  - From the Nivel, Netherlands Institute for Health Services Research, Utrecht.
FAU - Wagner, Cordula
AU  - Wagner C
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
PL  - United States
TA  - J Patient Saf
JT  - Journal of patient safety
JID - 101233393
SB  - IM
MH  - Hospitals
MH  - Humans
MH  - *Medical Errors/prevention & control
MH  - Netherlands
MH  - *Patient Safety
MH  - Retrospective Studies
EDAT- 2019/03/22 06:00
MHDA- 2021/11/25 06:00
CRDT- 2019/03/22 06:00
PHST- 2019/03/22 06:00 [pubmed]
PHST- 2021/11/25 06:00 [medline]
PHST- 2019/03/22 06:00 [entrez]
AID - 01209203-202106000-00008 [pii]
AID - 10.1097/PTS.0000000000000586 [doi]
PST - ppublish
SO  - J Patient Saf. 2021 Jun 1;17(4):282-289. doi: 10.1097/PTS.0000000000000586.