JRSM >
Volume 94, Number 7 >
Pp. 322-330
Clinical Risk Unit, Department of Psychology, University College London, London WC1E 6BT, UK
Correspondence: Dr Graham Neale
In a previous paper we reported that 10.8% of patients admitted to two large hospitals in Greater London experienced one or more adverse events, of which half were deemed preventable. Here we examine the underlying causes of errors in clinical practice. Rather than identifying specific errors made by individuals, we have looked at possible faults in the organization of care. Adverse events were grouped according to stages in the care process: diagnosis, preoperative assessment and care, operative or invasive procedure (including anaesthesia), ward management, use of drugs and intravenous fluids and discharge from hospital.
Less than 20% of preventable adverse events were directly related to surgical operations or invasive procedures and less than 10% to misdiagnoses. 53% of preventable adverse events occurred in general ward care (including initial assessment and the use of drugs and intravenous fluids) and 18% in care at the time of discharge. Probable contributory factors in these errors included dependence on diagnoses made by inexperienced clinicians, poor records, poor communication between professional carers, inadequate input by consultants into day-to-day care, and lack of detailed assessment of patients before discharge.
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  J. Escarrabill Discharge planning and home care for end-stage COPD patients Eur. Respir. J., August 1, 2009; 34(2): 507 - 512. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 I. A Scott Errors in clinical reasoning: causes and remedial strategies BMJ, June 8, 2009; 338(jun08_2): b1860 - b1860. [Full Text]
|
|
|
|
 |
|
 E N de Vries, M W Hollmann, S M Smorenburg, D J Gouma, and M A Boermeester Development and validation of the SURgical PAtient Safety System (SURPASS) checklist Qual. Saf. Health Care, April 1, 2009; 18(2): 121 - 126. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Vincent, P. Aylin, B. D. Franklin, A. Holmes, S. Iskander, A. Jacklin, and K. Moorthy Is health care getting safer? BMJ, November 13, 2008; 337(nov13_1): a2426 - a2426. [Full Text]
|
|
|
|
|
|
E N de Vries, M A Ramrattan, S M Smorenburg, D J Gouma, and M A Boermeester The incidence and nature of in-hospital adverse events: a systematic review Qual. Saf. Health Care, June 1, 2008; 17(3): 216 - 223. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. C. Dykes, A. Hurley, M. Cashen, S. Bakken, and M. E. Duffy Development and Psychometric Evaluation of the Impact of Health Information Technology (I-HIT) Scale J. Am. Med. Inform. Assoc., July 1, 2007; 14(4): 507 - 514. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Jacobs, M. O'Beirne, L. P. Derfiingher, L. Vlach, W. Rosser, and N. Drummond Errors and adverse events in family medicine: Developing and validating a Canadian taxonomy of errors Can Fam Physician, February 1, 2007; 53(2): 270 - 276. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M D Witham, P M Jenkins, and M E T McMurdo Using a sentinel adverse incident audit on a Medicine for the Elderly ward Qual. Saf. Health Care, December 1, 2006; 15(6): 446 - 447. [Full Text] [PDF]
|
|
|
|
|
|
R Amalberti, C Vincent, Y Auroy, and G de Saint Maurice Violations and migrations in health care: a framework for understanding and management Qual. Saf. Health Care, December 1, 2006; 15(suppl_1): i66 - i71. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Tamblyn, A. Huang, Y. Kawasumi, G. Bartlett, R. Grad, A. Jacques, M. Dawes, M. Abrahamowicz, R. Perreault, L. Taylor, et al. The Development and Evaluation of an Integrated Electronic Prescribing and Drug Management System for Primary Care J. Am. Med. Inform. Assoc., March 1, 2006; 13(2): 148 - 159. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Jagsi, B. T. Kitch, D. F. Weinstein, E. G. Campbell, M. Hutter, and J. S. Weissman Residents Report on Adverse Events and Their Causes Arch Intern Med, December 12, 2005; 165(22): 2607 - 2613. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O A Arah and N S Klazinga How safe is the safety paradigm? Qual. Saf. Health Care, June 1, 2004; 13(3): 226 - 232. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M Woloshynowych, G Neale, and C Vincent Case record review of adverse events: a new approach Qual. Saf. Health Care, December 1, 2003; 12(6): 411 - 415. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B Dean Adverse drug events: what's the truth? Qual. Saf. Health Care, June 1, 2003; 12(3): 165 - 165. [Full Text]
|
|
|
|
 |
|
 A. E. Carroll, P. Tarczy-Hornoch, E. O'Reilly, and D. A. Christakis Resident Documentation Discrepancies in a Neonatal Intensive Care Unit Pediatrics, May 1, 2003; 111(5): 976 - 980. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P Ramnarayan, A Tomlinson, A Rao, M Coren, A Winrow, and J Britto ISABEL: a web-based differential diagnostic aid for paediatrics: results from an initial performance evaluation Arch. Dis. Child., May 1, 2003; 88(5): 408 - 413. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G Neale and M Woloshynowych Retrospective case record review: a blunt instrument that needs sharpening Qual. Saf. Health Care, February 1, 2003; 12(1): 2 - 3. [Full Text] [PDF]
|
|
|
|
|
|
B Dean Learning from prescribing errors Qual. Saf. Health Care, September 1, 2002; 11(3): 258 - 260. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R J Lilford Patient safety research: does it have legs? Qual. Saf. Health Care, June 1, 2002; 11(2): 113 - 114. [Full Text] [PDF]
|
|
