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Chapter 7 - Reporting Adverse Events

from Section 3 - Reporting and Databases

Published online by Cambridge University Press:  27 July 2023

Sally E. Rampersad
Affiliation:
University of Washington School of Medicine, Seattle
Cindy B. Katz
Affiliation:
Seattle Children’s Hospital, Washington
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Publisher: Cambridge University Press
Print publication year: 2023

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References

Rafter, N, Hickey, A, Condell, S, et al. Adverse events in healthcare: Learning from mistakes. QJM. 2015;108(4):273277. doi: 10.1093/qjmed/hcu145 [published Online First: 2014/08/01].CrossRefGoogle Scholar
Resar, RK, Rozich, JD, and Classen, D. Methodology and rationale for the measurement of harm with trigger tools. Quality & Safety in Health Care. 2003;12(Suppl 2):ii39–45. [published Online First: 2003/12/04].CrossRefGoogle Scholar
Stockwell, DC, Bisarya, H, Classen, DC, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):10361042. doi: 10.1542/peds.2014-2152 [published Online First: 2015/05/20].CrossRefGoogle Scholar
Levtzion-Korach, O, Frankel, A, Alcalai, H, et al. Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant. Joint Commission Journal on Quality and Patient Safety. 2010;36(9):402410. [published Online First: 2010/09/30].Google Scholar
Naessens, JM, Campbell, CR, Huddleston, JM, et al. A comparison of hospital adverse events identified by three widely used detection methods. International Journal of Quality Health Care. 2009;21(4):301307. doi: 10.1093/intqhc/mzp027 [published Online First: 2009/07/21].CrossRefGoogle Scholar
Kohn, LT, Corrigan, JM, and Donaldson, MS, eds. To Err is Human. Institute of Medicine (US) Committee on Quality of Health Care in America. Washington, DC, National Academies Press, 2000. Available from www.ncbi.nlm.nih.gov/books/NBK225174/ (Accessed 7/10/22).Google Scholar
Leonard, MS. Patient safety and quality improvement: medical errors and adverse events. Pediatrics in Review 2010;31(4):151158. doi: 10.1542/pir.31-4-151 [published Online First: 2010/04/03].CrossRefGoogle Scholar
Griffin FA RR. IHI global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series White Paper. Cambridge, MA, Institute for Healthcare Improvement; 2009.Google Scholar
Jick, H. Drugs--remarkably nontoxic. New England Journal of Medicine. 1974;291(16):824–828. doi: 10.1056/NEJM197410172911605 [published Online First: 1974/10/17].CrossRefGoogle Scholar
Leape, LL. Errors in medicine. Clinica Chimica Acta. 2009;404(1):25. doi: 10.1016/j.cca.2009.03.020 [published Online First: 2009/03/24].CrossRefGoogle Scholar
Leape, LL, Brennan, TA, Laird, N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine. 1991;324(6):377384. doi: 10.1056/NEJM199102073240605 [published Online First: 1991/02/07].Google Scholar
Staender, S. Incident reporting in anaesthesiology. Best Practice and Research in Clinical Anaesthesiology. 2011;25(2):207214. doi: 10.1016/j.bpa.2011.01.005 [published Online First: 2011/05/10].Google Scholar
Guffey, PJ, Culwick, M, and Merry, AF. Incident reporting at the local and national level. International Anesthesiology Clinics. 2014;52(1):6983. Doi: 10.1097/AIA.0000000000000008 [published Online First: 2013/12/29].Google Scholar
Flanagan, JC. The critical incident technique. Psychological Bulletin. 1954;51(4):327358. [published Online First: 1954/07/01].CrossRefGoogle Scholar
Cooper, JB, Newbower, RS, Long, CD, et al. Preventable anesthesia mishaps: A study of human factors. Anesthesiology. 1978;49(6):399406. [published Online First: 1978/12/01].Google Scholar
Williams, GD, Muffly, MK, Mendoza, JM, et al. Reporting of perioperative adverse events by pediatric anesthesiologists at a Tertiary Children’s Hospital: Targeted interventions to increase the rate of reporting. Anesthesia and Analgesia. 2017;125(5):15151523. doi: 10.1213/ANE.0000000000002208 [published Online First: 2017/07/06].CrossRefGoogle Scholar
Farley, DO, Haviland, A, Champagne, S, et al. Adverse-event-reporting practices by US hospitals: Results of a national survey. Quality & Safety in Health Care. 2008;17(6):416423. doi: 10.1136/qshc.2007.024638 [published Online First: 2008/12/10].CrossRefGoogle Scholar
Haller, G, Courvoisier, DS, Anderson, H, et al. Clinical factors associated with the non-utilization of an anaesthesia incident reporting system. British Journal of Anaesthesia. 2011;107(2):171179. doi: 10.1093/bja/aer148 [published Online First: 2011/06/07].Google Scholar
Peterfreund, RA, Driscoll, WD, Walsh, JL, et al. Evaluation of a mandatory quality assurance data capture in anesthesia: A secure electronic system to capture quality assurance information linked to an automated anesthesia record. Anesthesia and Analgesia. 2011;112(5):12181225. doi: 10.1213/ANE.0b013e31821207f0 [published Online First: 2011/03/19].CrossRefGoogle Scholar
Larizgoitia, I, Bouesseau, MC, and Kelley, E. WHO efforts to promote reporting of adverse events and global learning. Journal of Public Health Research. 2013;2(3):e29. doi: 10.4081/jphr.2013.e29 [published Online First: 2014/08/30].CrossRefGoogle Scholar
Tjia, I, Rampersad, S, Varughese, A, et al. Wake Up Safe and root cause analysis: Quality improvement in pediatric anesthesia. Anesthesia and Analgesia. 2014;119(1):122136. doi: 10.1213/ANE.0000000000000266 [published Online First: 2014/06/20].Google Scholar
Rowin, EJ, Lucier, D, Pauker, SG, et al. Does error and adverse event reporting by physicians and nurses differ? Joint Commission Journal of Quality and Patient Safety. 2008;34(9):537545. [published Online First: 2008/09/17].CrossRefGoogle Scholar
Heard, GC, Sanderson, PM, and Thomas, RD. Barriers to adverse event and error reporting in anesthesia. Anesthesia and Analgesia. 2012;114(3):604614. doi: 10.1213/ANE.0b013e31822649e8 [published Online First: 2011/08/09].Google Scholar
Mahajan, RP. Critical incident reporting and learning. British Journal of Anaesthesia. 2010;105(1):6975. doi: 10.1093/bja/aeq133 [published Online First: 2010/06/17].Google Scholar
Guffey, P, Szolnoki, J, Caldwell, J, et al. Design and implementation of a near-miss reporting system at a large, academic pediatric anesthesia department. Paediatric Anaesthesia. 2011;21(7):810814. doi: 10.1111/j.1460-9592.2011.03574.x [published Online First: 2011/05/04].CrossRefGoogle Scholar
Murff, HJ, Patel, VL, Hripcsak, G, et al. Detecting adverse events for patient safety research: A review of current methodologies. Journal of Biomedical Informatics. 2003;36(1–2):131143. [published Online First: 2003/10/14].CrossRefGoogle Scholar
Brennan, TA, Leape, LL, Laird, NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine. 1991;324(6):370376. doi: 10.1056/NEJM199102073240604 [published Online First: 1991/02/07].Google Scholar
Hiatt, HH, Barnes, BA, Brennan, TA, et al. A study of medical injury and medical malpractice. New England Journal of Medicine. 1989;321(7):480484. doi: 10.1056/NEJM198908173210725 [published Online First: 1989/08/17].Google Scholar
Baker, GR, Norton, PG, Flintoft, V, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):16781686. [published Online First: 2004/05/26].CrossRefGoogle Scholar
Classen, DC, Lloyd, RC, Provost, L, et al. Development and evaluation of the Institute for Healthcare Improvement Global Trigger Tool. 2008;4(3):169177. doi: 10.1097/PTS.0b013e318183a475.Google Scholar
Classen, DC, Pestotnik, SL, Evans, RS, et al. Description of a computerized adverse drug event monitor using a hospital information system. Hospital Pharmacy. 1992;27(9):774, 76–79, 83. [published Online First: 1992/09/01].Google Scholar
Classen, DC, Resar, R, Griffin, F, et al. “Global trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs (Millwood). 2011;30(4):581589. doi: 10.1377/hlthaff.2011.0190 [published Online First: 2011/04/08].CrossRefGoogle Scholar
Howe, CL. A review of the Office of Inspector General’s reports on adverse event identification and reporting. Journal of Healthcare Risk Management. 2011;30(4):4854. doi: 10.1002/jhrm.20068 [published Online First: 2011/04/21].Google Scholar
Rutberg, H, Borgstedt Risberg, M, Sjodahl, R, et al. Characterisations of adverse events detected in a university hospital: A 4-year study using the Global Trigger Tool method. BMJ Open. 2014;4(5):e004879. doi: 10.1136/bmjopen-2014-004879 [published Online First: 2014/05/30].Google Scholar
Sharek, PJ and Classen, D. The incidence of adverse events and medical error in pediatrics. Pediatric Clinics of North America. 2006;53(6):10671077. doi: 10.1016/j.pcl.2006.09.011 [published Online First: 2006/11/28].Google Scholar
Blumenthal, S. The use of clinical registries in the United States: A landscape survey. EGEMS (Washington DC). 2017;5(1):26. doi: 10.5334/egems.248 [published Online First: 2018/06/23].CrossRefGoogle Scholar
Hall, BL, Hamilton, BH, Richards, K, et al. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: An evaluation of all participating hospitals. Annals of Surgery. 2009;250(3):363376. doi: 10.1097/SLA.0b013e3181b4148f [published Online First: 2009/08/01].Google Scholar
Khuri, SF. The NSQIP: A new frontier in surgery. Surgery. 2005;138(5):837843. doi: 10.1016/j.surg.2005.08.016 [published Online First: 2005/11/18].CrossRefGoogle Scholar
Khuri, SF, Daley, J, Henderson, W, et al. The Department of Veterans Affairs’ NSQIP: The first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Annals of Surgery. 1998;228(4):491507. [published Online First: 1998/10/28]Google Scholar
Khuri, SF, Henderson, WG, Daley, J, et al. Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: The Patient Safety in Surgery study. Annals of Surgery. 2008;248(2):329336. doi: 10.1097/SLA.0b013e3181823485 [published Online First: 2008/07/25].CrossRefGoogle Scholar
Dutton, RP. Registries of the anesthesia quality institute. International Anesthesiology Clinics. 2014;52(1):114. doi: 10.1097/AIA.0000000000000001 [published Online First: 2013/12/29].CrossRefGoogle Scholar
Dutton, RP and Dukatz, A. Quality improvement using automated data sources: The anesthesia quality institute. Anesthesiology Clinics. 2011;29(3):439454. doi: 10.1016/j.anclin.2011.05.002 [published Online First: 2011/08/30].Google Scholar
Liau, A, Havidich, JE, Onega, T, et al. The National Anesthesia Clinical Outcomes Registry. Anesthesia and Analgesia. 2015;121(6):16041610. doi: 10.1213/ane.0000000000000895 [published Online First: 2015/11/19].CrossRefGoogle Scholar
Thomas, EG, Andrew, D, Hubert, AK, et al. Bring Out Your Data: The Evolution of the National Anesthesia Clinical Outcomes Registry (NACOR). International Journal of Computational Models and Algorithms in Medicine (IJCMAM). 2011;2(2):5169. doi: 10.4018/jcmam.2011040104.CrossRefGoogle Scholar
Dutton, RP. Large databases in anaesthesiology. Current Opinion in Anaesthesiology. 2015;28(6):697702. doi: 10.1097/ACO.0000000000000243 [published Online First: 2015/09/30].CrossRefGoogle Scholar
Deiner, S, Westlake, B, and Dutton, RP. Patterns of surgical care and complications in elderly adults. Journal of the American Geriatrics Society. 2014;62(5):829835. doi: 10.1111/jgs.12794 [published Online First: 2014/04/16].CrossRefGoogle Scholar
Dexter, F, Dutton, RP, Kordylewski, H, et al. Anesthesia workload nationally during regular workdays and weekends. Anesthesia and Analgesia. 2015;121(6):16001603. doi: 10.1213/ANE.0000000000000773 [published Online First: 2015/04/30].CrossRefGoogle Scholar
Nunnally, ME, O’Connor, MF, Kordylewski, H, et al. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. Anesthesia and Analgesia. 2015;120(2):364370. doi: 10.1213/ANE.0000000000000527 [published Online First: 2014/11/13].Google Scholar
Shapiro, FE, Jani, SR, Liu, X, et al. Initial results from the National Anesthesia Clinical Outcomes Registry and overview of office-based anesthesia. Anesthesiology Clinics. 2014;32(2):431444. doi: 10.1016/j.anclin.2014.02.018 [published Online First: 2014/06/03].CrossRefGoogle Scholar
Wake Up Safe. Available from: http://wakeupsafe.org/ (Accessed 27/01/2019).Google Scholar
Anesthesia Closed Claims Project. [cited 2019 January 27]. Available from: https://depts.washington.edu/asaccp/welcome-anesthesia-closed-claims-project-its-registries.Google Scholar
Cheney, FW. The American Society of Anesthesiologists Closed Claims Project: What have we learned, how has it affected practice, and how will it affect practice in the future? Anesthesiology. 1999;91(2):552556. [published Online First: 1999/08/12].Google Scholar
Jha, AK and Classen, DC. Getting moving on patient safety–harnessing electronic data for safer care. New England Journal of Medicine. 2011;365(19):17561758. doi: 10.1056/NEJMp1109398 [published Online First: 2011/11/11].CrossRefGoogle Scholar
Psaty, BM, Delaney, JA, Arnold, AM, et al. Study of cardiovascular health outcomes in the era of claims data: The Cardiovascular Health Study. Circulation. 2016;133(2):156164. doi: 10.1161/CIRCULATIONAHA.115.018610 [published Online First: 2015/11/06].CrossRefGoogle Scholar
Agency for Healthcare Research and Quality. AHRQ Quality Indicators]. Available from: www.qualityindicators.ahrq.gov (Accessed 7/10/2022).Google Scholar
Farquhar, M. Chapter 45: AHRQ Quality Indicators. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD, Agency for Healthcare Research and Quality (US), April 2008.Google Scholar
Narain, W. Assessing estimates of patient safety derived from coded data. Journal of Healthcare Quality. 2017;39(4):230242. doi: 10.1097/JHQ.0000000000000088 [published Online First: 2017/06/29].Google Scholar
Classen, DC, Pestotnik, SL, Evans, RS, et al. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266(20):28472851. [published Online First: 1991/11/27].Google Scholar
Sips, ME, Bonten, MJM, and van Mourik, MSM. Automated surveillance of healthcare-associated infections: State of the art. Current Opinion in Infectious Diseases. 2017;30(4):425431. Doi: 10.1097/QCO.0000000000000376 [published Online First: 2017/05/16].Google Scholar
Kilbridge, PM and Classen, DC. Automated surveillance for adverse events in hospitalized patients: Back to the future. Quality & Safety in Health Care. 2006;15(3):148149. doi: 10.1136/qshc.2006.018218 [published Online First: 2006/06/06].Google Scholar
Klompas, M and Yokoe, DS. Automated surveillance of health care-associated infections. Clinical Infectious Disease. 2009;48(9):12681275. doi: 10.1086/597591 [published Online First: 2009/04/02].Google Scholar
King, A, Daniels, J, Lim, J, et al. Time to listen: a review of methods to solicit patient reports of adverse events. Quality & Safety in Health Care. 2010;19(2):148157. doi: 10.1136/qshc.2008.030114 [published Online First: 2010/03/31].CrossRefGoogle Scholar
Weingart, SN, Pagovich, O, Sands, DZ, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. Journal of General Internal Medicine. 2005;20(9):830836. doi: 10.1111/j.1525-1497.2005.0180.x [published Online First: 2005/08/25].CrossRefGoogle Scholar
Zhu, J, Stuver, SO, Epstein, AM, et al. Can we rely on patients’ reports of adverse events? Medical Care. 2011;49(10):948955. doi: 10.1097/MLR.0b013e31822047a8 [published Online First: 2011/06/07].Google Scholar
Weingart, SN. Patient-reported adverse events: What are we waiting for? Joint Commission Journal on Quality & Patient Safety. 2011;37(11):494. [published Online First: 2011/12/03].CrossRefGoogle Scholar
Weissman, JS, Schneider, EC, Weingart, SN, et al. Comparing patient-reported hospital adverse events with medical record review: Do patients know something that hospitals do not? Annals of Internal Medicine. 2008;149(2):100108. [published Online First: 2008/07/16].CrossRefGoogle Scholar
Hasegawa, T, Fujita, S, Seto, K, et al. Patients’ identification and reporting of unsafe events at six hospitals in Japan. Joint Commission Journal on Quality & Patient Safety. 2011;37(11):502508. [published Online First: 2011/12/03].CrossRefGoogle Scholar
Khan, A, Furtak, SL, Melvin, P, et al. Parent-reported errors and adverse events in hospitalized children. JAMA Pediatrics. 2016;170(4):e154608. doi: 10.1001/jamapediatrics.2015.4608 [published Online First: 2016/03/02].Google Scholar
Ohrn, A, Elfstrom, J, Liedgren, C, et al. Reporting of sentinel events in Swedish hospitals: A comparison of severe adverse events reported by patients and providers. Joint Commission Journal on Quality & Patient Safety. 2011;37(11):495501. [published Online First: 2011/12/03].Google Scholar
Weingart, SN, Price, J, Duncombe, D, et al. Patient-reported safety and quality of care in outpatient oncology. Joint Commission Journal on Quality & Patient Safety. 2007;33(2):8394. [published Online First: 2007/03/21].Google Scholar
Olsen, S, Neale, G, Schwab, K, et al. Hospital staff should use more than one method to detect adverse events and potential adverse events: Incident reporting, pharmacist surveillance and local real-time record review may all have a place. Quality & Safety in Health Care. 2007;16(1):4044. doi: 10.1136/qshc.2005.017616 [published Online First: 2007/02/16].Google Scholar

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