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Injury and Death Associated With Incidents Reported to the Patient Safety Net
Mark Reid, MD*,
Raymond Estacio, MD,
and
Rick Albert, MD
Denver Health Medical Center, Colorado
* To whom correspondence should be addressed. E-mail: mark.reid{at}dhha.org.
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Abstract |
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The authors retrospectively evaluated anonymously submitted inpatient medical error reports from 8 institutions participating in the University HealthSystem Consortium Patient Safety Net (PSN) in 2004 in an attempt to focus patient safety efforts on problems that were most commonly associated with harm. Of the 25 300 incidents reported, 3381 (13.3%) were associated with adverse events (AEs), and 109 (0.4%) were associated with death. Although the most commonly reported categories of incidents associated with AEs were complications of procedure/treatment/test (29%), falls (17%), and medication errors (10%), the taxonomy of the PSN limited efforts to find specific errors in care that might be addressed by attempts to improve patient safety. Skin breakdown and falls were confirmed as presenting substantial risks to hospitalized patients, in that 59% of the incidents reported in the skin integrity category and 22% of falls resulted in AEs. The benefits and limitations of a voluntary reporting system are discussed. (Am J Med Qual 2009;24:xx-xx)
First published on September 4, 2009, doi:10.1177/1062860609345788
American Journal of Medical Quality 2009;24:520.
A more recent version of this article appeared on November 1, 2009
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