A comparison of hospital adverse events identified by three widely used detection methods

James M Naessens, Claudia R. Campbell, Jeanne M. Huddleston, Bjorn P. Berg, John J. Lefante, Arthur R. Williams, Richard A. Culbertson

Research output: Contribution to journalArticle

97 Citations (Scopus)

Abstract

Objective. Determine the degree of congruence between several measures of adverse events. Design Cross-sectional study to assess frequency and type of adverse events identified using a variety of methods. Setting. Mayo Clinic Rochester hospitals. Participants. All inpatients discharged in 2005 (n = 60 599). Interventions. Adverse events were identified through multiple methods: (i) Agency for Healthcare Research and Quality-defined patient safety indicators (PSIs) using ICD-9 diagnosis codes from administrative discharge abstracts, (ii) provider-reported events, and (iii) Institute for Healthcare Improvement Global Trigger Tool with physician confirmation. PSIs were adjusted to exclude patient conditions present at admission. Main outcome measure. Agreement of identification between methods. Results. About 4% (2401) of hospital discharges had an adverse event identified by at least one method. Around 38% (922) of identified events were provider-reported events. Nearly 43% of provider-reported adverse events were skin integrity events, 23% medication events, 21% falls, 1.8% equipment events and 37% miscellaneous events. Patients with adverse events identified by one method were not usually identified using another method. Only 97 (6.2%) of hospitalizations with a PSI also had a provider-reported event and only 10.5% of provider-reported events had a PSI. Conclusions. Different detection methods identified different adverse events. Findings are consistent with studies that recommend combining approaches to measure patient safety for internal quality improvement. Potential reported adverse event inconsistencies, low association with documented harm and reporting differences across organizations, however, raise concerns about using these patient safety measures for public reporting and organizational performance comparison.

Original languageEnglish (US)
Pages (from-to)301-307
Number of pages7
JournalInternational Journal for Quality in Health Care
Volume21
Issue number4
DOIs
StatePublished - 2009

Fingerprint

Patient Safety
Health Care Quality Indicators
Health Services Research
International Classification of Diseases
Quality Improvement
Inpatients
Hospitalization
Cross-Sectional Studies
Outcome Assessment (Health Care)
Organizations
Physicians
Equipment and Supplies
Skin

Keywords

  • Adverse events
  • Patient safety
  • Quality measurement
  • Reported events

ASJC Scopus subject areas

  • Health Policy
  • Public Health, Environmental and Occupational Health

Cite this

Naessens, J. M., Campbell, C. R., Huddleston, J. M., Berg, B. P., Lefante, J. J., Williams, A. R., & Culbertson, R. A. (2009). A comparison of hospital adverse events identified by three widely used detection methods. International Journal for Quality in Health Care, 21(4), 301-307. https://doi.org/10.1093/intqhc/mzp027

A comparison of hospital adverse events identified by three widely used detection methods. / Naessens, James M; Campbell, Claudia R.; Huddleston, Jeanne M.; Berg, Bjorn P.; Lefante, John J.; Williams, Arthur R.; Culbertson, Richard A.

In: International Journal for Quality in Health Care, Vol. 21, No. 4, 2009, p. 301-307.

Research output: Contribution to journalArticle

Naessens, JM, Campbell, CR, Huddleston, JM, Berg, BP, Lefante, JJ, Williams, AR & Culbertson, RA 2009, 'A comparison of hospital adverse events identified by three widely used detection methods', International Journal for Quality in Health Care, vol. 21, no. 4, pp. 301-307. https://doi.org/10.1093/intqhc/mzp027
Naessens, James M ; Campbell, Claudia R. ; Huddleston, Jeanne M. ; Berg, Bjorn P. ; Lefante, John J. ; Williams, Arthur R. ; Culbertson, Richard A. / A comparison of hospital adverse events identified by three widely used detection methods. In: International Journal for Quality in Health Care. 2009 ; Vol. 21, No. 4. pp. 301-307.
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