Literature DB >> 16076793

Adverse events and near miss reporting in the NHS.

R Shaw1, F Drever, H Hughes, S Osborn, S Williams.   

Abstract

OBJECTIVES: To conduct a multicentre study on adverse event and near miss reporting in the NHS and to explore the feasibility of creating a national system for collecting these data.
DESIGN: Prospective voluntary reporting by staff with anonymised transfer of data was used by a national system to collect data from 18 NHS trusts. PARTICIPANTS: Staff from 12 acute trusts, three mental health trusts, two ambulance trusts, and one primary care trust. MAIN OUTCOMES MEASURED: Number of incidents, date and time of incident, patient age and sex, clinical speciality, location, outcome, risk rating, type and description of incident.
RESULTS: A total of 28 998 incidents were reported including 11 766 (41%) slips, trips and falls, 2514 (9%) medication management incidents, 2429 (8%) resource issues, and 2164 (7%) treatment issues. 138 catastrophic and 260 major adverse outcomes were reported. Slips, trips and falls (n = 11 766) were the most common type of incident.
CONCLUSIONS: Voluntary reporting by staff when linked to a multicentre data collecting system can yield information on a large number of incidents. This provides support for the principle of creating a national IT system to collect and analyse incident data.

Entities:  

Mesh:

Year:  2005        PMID: 16076793      PMCID: PMC1744051          DOI: 10.1136/qshc.2004.010553

Source DB:  PubMed          Journal:  Qual Saf Health Care        ISSN: 1475-3898


  10 in total

1.  Not again!

Authors:  D M Berwick
Journal:  BMJ       Date:  2001-02-03

2.  Epidemiology of medical error.

Authors:  S N Weingart; R M Wilson; R W Gibberd; B Harrison
Journal:  BMJ       Date:  2000-03-18

3.  Adverse events in British hospitals: preliminary retrospective record review.

Authors:  C Vincent; G Neale; M Woloshynowych
Journal:  BMJ       Date:  2001-03-03

4.  Ethnographic study of incidence and severity of intravenous drug errors.

Authors:  Katja Taxis; Nick Barber
Journal:  BMJ       Date:  2003-03-29

5.  Views of practicing physicians and the public on medical errors.

Authors:  Robert J Blendon; Catherine M DesRoches; Mollyann Brodie; John M Benson; Allison B Rosen; Eric Schneider; Drew E Altman; Kinga Zapert; Melissa J Herrmann; Annie E Steffenson
Journal:  N Engl J Med       Date:  2002-12-12       Impact factor: 91.245

6.  Reporting of adverse events.

Authors:  Lucian L Leape
Journal:  N Engl J Med       Date:  2002-11-14       Impact factor: 91.245

7.  Physician and public opinions on quality of health care and the problem of medical errors.

Authors:  Andrew R Robinson; Kirsten B Hohmann; Julie I Rifkin; Daniel Topp; Christine M Gilroy; Jeffrey A Pickard; Robert J Anderson
Journal:  Arch Intern Med       Date:  2002-10-28

8.  The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II.

Authors:  L L Leape; T A Brennan; N Laird; A G Lawthers; A R Localio; B A Barnes; L Hebert; J P Newhouse; P C Weiler; H Hiatt
Journal:  N Engl J Med       Date:  1991-02-07       Impact factor: 91.245

9.  The Quality in Australian Health Care Study.

Authors:  R M Wilson; W B Runciman; R W Gibberd; B T Harrison; L Newby; J D Hamilton
Journal:  Med J Aust       Date:  1995-11-06       Impact factor: 7.738

10.  Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.

Authors:  T A Brennan; L L Leape; N M Laird; L Hebert; A R Localio; A G Lawthers; J P Newhouse; P C Weiler; H H Hiatt
Journal:  N Engl J Med       Date:  1991-02-07       Impact factor: 91.245

  10 in total
  21 in total

1.  A Novel Schema to Enhance Data Quality of Patient Safety Event Reports.

Authors:  Hong Kang; Yang Gong
Journal:  AMIA Annu Symp Proc       Date:  2017-02-10

2.  Attitudes to reporting medication error among differing healthcare professionals.

Authors:  Ajit Sarvadikar; Gordon Prescott; David Williams
Journal:  Eur J Clin Pharmacol       Date:  2010-06-08       Impact factor: 2.953

3.  Near misses and research subjects.

Authors:  H J Murff; R S Dittus
Journal:  Qual Saf Health Care       Date:  2006-08

4.  Using a sentinel adverse incident audit on a Medicine for the Elderly ward.

Authors:  M D Witham; P M Jenkins; M E T McMurdo
Journal:  Qual Saf Health Care       Date:  2006-12

5.  Initializing and Growing a Database of Health Information Technology (HIT) Events by Using TF-IDF and Biterm Topic Modeling.

Authors:  Hong Kang; Zhiguo Yu; Yang Gong
Journal:  AMIA Annu Symp Proc       Date:  2018-04-16

6.  Investigation of medical error-reporting system and reporting status in Iran in 2019.

Authors:  Asaad Ranaei; Hasan Abolghasem Gorji; Aidin Aryankhesal; Mostafa Langarizadeh
Journal:  J Educ Health Promot       Date:  2020-10-30

7.  Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors.

Authors:  Olga Kostopoulou; Brendan Delaney
Journal:  Qual Saf Health Care       Date:  2007-04

Review 8.  Enhancing Patient Safety Event Reporting. A Systematic Review of System Design Features.

Authors:  Yang Gong; Hong Kang; Xinshuo Wu; Lei Hua
Journal:  Appl Clin Inform       Date:  2017-08-30       Impact factor: 2.342

9.  Rates and types of events reported to established incident reporting systems in two US hospitals.

Authors:  Teryl K Nuckols; Douglas S Bell; Honghu Liu; Susan M Paddock; Lee H Hilborne
Journal:  Qual Saf Health Care       Date:  2007-06

10.  Evaluation of clinically significant adverse events in patients discharged from a tertiary-care emergency department in Taiwan.

Authors:  Lee-Min Wang; Chorng-Kuang How; Ming-Chin Yang; Syi Su; Chii-Hwa Chern
Journal:  Emerg Med J       Date:  2012-03-20       Impact factor: 2.740

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