PMID- 32019518
OWN - NLM
STAT- MEDLINE
DCOM- 20201109
LR  - 20201109
IS  - 1471-244X (Electronic)
IS  - 1471-244X (Linking)
VI  - 20
IP  - 1
DP  - 2020 Feb 4
TI  - Adverse events in psychiatry: a national cohort study in Sweden with a unique 
      psychiatric trigger tool.
PG  - 44
LID - 10.1186/s12888-020-2447-2 [doi]
LID - 44
AB  - BACKGROUND: The vast majority of patient safety research has focused on somatic 
      health care. Although specific adverse events (AEs) within psychiatric healthcare 
      have been explored, the overall level and nature of AEs is sparsely investigated. 
      METHODS: Cohort study using a retrospective record review based on a two-step 
      trigger tool methodology in the charts of randomly selected patients 18 years or 
      older admitted to the psychiatric acute care departments in all Swedish regions 
      from January 1 to June 30, 2017. Hospital care together with corresponding 
      outpatient care were reviewed as a continuum, over a maximum of 3 months. The AEs 
      were categorised according to type, severity and preventability. RESULTS: In 
      total, the medical records of 2552 patients were reviewed. Among the patients, 
      50.4% were women and 49.6% were men. The median (range) age was 44 (18-97) years 
      for women and 44.5 (18-93) years for men. In 438 of the reviewed records, 720 AEs 
      were identified, corresponding to the AEs identified in 17.2% [95% confidence 
      interval, 15.7-18.6] of the records. The majority of AEs resulted in less or 
      moderate harm, and 46.2% were considered preventable. Prolonged disease 
      progression and deliberate self-harm were the most common types of AEs. AEs were 
      significantly more common in women (21.5%) than in men (12.7%) but showed no 
      difference between age groups. Severe or catastrophic harm was found in 2.3% of 
      the records, and the majority affected were women (61%). Triggers pointing at 
      deficient quality of care were found in 78% of the records, with the absence of a 
      treatment plan being the most common. CONCLUSIONS: AEs are common in psychiatric 
      care. Aside from further patient safety work, systematic interventions are also 
      warranted to improve the quality of psychiatric care.
FAU - Nilsson, Lena
AU  - Nilsson L
AUID- ORCID: 0000-0002-7489-9077
AD  - Department of Anaesthesiology and Intensive Care, Department of Biomedical and 
      Clinical Sciences, Linkoping University, Linkoping, Sweden. 
      lena.nilsson@regionostergotland.se.
AD  - Department of Anaesthesiology and Intensive Care, University Hospital, 583 81, 
      Linkoping, Sweden. lena.nilsson@regionostergotland.se.
FAU - Borgstedt-Risberg, Madeleine
AU  - Borgstedt-Risberg M
AD  - Centre for Organisational Support and Development (CVU), Region Ostergotland, 
      Linkoping University, Linkoping, Sweden.
FAU - Brunner, Charlotta
AU  - Brunner C
AD  - Department of Psychiatry, Kalmar County Council, Kalmar, Sweden.
FAU - Nyberg, Ullakarin
AU  - Nyberg U
AD  - Stockholm Centre for Psychiatric Research and Education, Department of Clinical 
      Neuroscience, Karolinska Institutet, Stockholm, Sweden.
FAU - Nylen, Urban
AU  - Nylen U
AD  - National Board of Health and Welfare, Stockholm, Sweden.
FAU - Alenius, Carina
AU  - Alenius C
AD  - Swedish Association of Local Authorities and Regions, Stockholm, Sweden.
FAU - Rutberg, Hans
AU  - Rutberg H
AD  - Swedish Association of Local Authorities and Regions, Stockholm, Sweden.
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
DEP - 20200204
PL  - England
TA  - BMC Psychiatry
JT  - BMC psychiatry
JID - 100968559
SB  - IM
MH  - Cohort Studies
MH  - Female
MH  - Humans
MH  - Male
MH  - *Medical Errors
MH  - Patient Safety
MH  - *Psychiatry
MH  - Retrospective Studies
MH  - Sweden
PMC - PMC7001519
OTO - NOTNLM
OT  - Adverse event
OT  - Patient harm
OT  - Patient safety
OT  - Psychiatry
OT  - Trigger tool
COIS- The authors declare that they have no competing interests.
EDAT- 2020/02/06 06:00
MHDA- 2020/11/11 06:00
PMCR- 2020/02/04
CRDT- 2020/02/06 06:00
PHST- 2019/06/05 00:00 [received]
PHST- 2020/01/21 00:00 [accepted]
PHST- 2020/02/06 06:00 [entrez]
PHST- 2020/02/06 06:00 [pubmed]
PHST- 2020/11/11 06:00 [medline]
PHST- 2020/02/04 00:00 [pmc-release]
AID - 10.1186/s12888-020-2447-2 [pii]
AID - 2447 [pii]
AID - 10.1186/s12888-020-2447-2 [doi]
PST - epublish
SO  - BMC Psychiatry. 2020 Feb 4;20(1):44. doi: 10.1186/s12888-020-2447-2.