The nature and causes of unintended events reported at ten emergency departments

BMC Emergency Medicine - Tập 9 Số 1 - 2009
Marleen Smits1, Peter Groenewegen1, Daniëlle R.M. Timmermans2, Gerrit van der Wal2, Cordula Wagner2
1Nivel (Netherlands Institute for Health Services Research), Utrecht, the Netherlands
2Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands

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Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991, 324: 370-376.

Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD: The quality in Australian health care study. Med J Aust. 1995, 163: 458-471.

Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, Howard KM, Weiler PC, Brennan TA: Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000, 38: 261-271. 10.1097/00005650-200003000-00003.

Schioler T, Lipczak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A, Svenning AR, Frølich A: Incidence of adverse events in hospitals. A retrospective study of medical records (In Danish). Ugeskr Laeger. 2001, 163: 5370-5378.

Vincent C, Neale G, Woloshynowych M: Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001, 322: 517-519. 10.1136/bmj.322.7285.517.

Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S: Adverse events in New Zealand public hospitals I: occurrence and impact. N Z Med J. 2002, 115: U271-

Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, Etchells E, Ghali WA, Hébert P, Majumdar SR, O'Beirne M, Palacios-Derflingher L, Reid RJ, Sheps S, Tamblyn R: The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004, 170: 1678-1686.

Michel P, Quenon JL, De Sarasqueta AM, Scemama O: Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ. 2004, 328: 199-10.1136/bmj.328.7433.199.

Zegers M, De Bruijne MC, Wagner C, Hoonhout LHF, Waaijman R, Smits M, Hout FAG, Zwaan L, Christiaans-Dingelhoff I, Timmermans DRM, Groenewegen PP, Wal van der G: Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care. 2009, 18: 297-302. 10.1136/qshc.2007.025924.

Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H: The nature of adverse events in hospitalized patients: results of the Harvard medical practice study II. N Engl J Med. 1991, 324: 377-384.

Driscoll P, Thomas M, Touquet R, Fothergill J: Risk management in accident and emergency medicine. Clinical risk management. Edited by: Vincent C. 2001, London: BMJ Books, 151-173.

Fordyce J, Blank FSJ, Pekow P, Smithline HA, Ritter G, Gehlbach S, Benjamin E, Henneman PL: Errors in a busy emergency department. Ann Emerg Med. 2003, 42: 324-333. 10.1016/S0196-0644(03)00398-6.

Institute of Medicine: To err is human: building a safer health system. 1999, Washington DC: National Academy Press

Kanse L, Schaaf van der TW, Vrijland ND, van Mierlo H: Error recovery in a hospital pharmacy. Ergonomics. 2006, 49: 503-516. 10.1080/00140130600568741.

Wright L, Schaaf van der TW: Accident versus near miss causation: a critical review of the literature, an empirical test in the UK railway domain, and their implications for other sectors. Journal of Hazardous Materials. 2004, 111: 105-110. 10.1016/j.jhazmat.2004.02.049.

Milch CE, Salem DN, Pauker SG, Lundquist TG, Kumar S, Chen J: Voluntary electronic reporting of medical errors and adverse events: An analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med. 2006, 21: 165-170.

Tighe CM, Woloshynowych M, Brown R, Wears B, Vincent C: Incident reporting in one UK accident and emergency department. Accid Emerg Nurs. 2006, 14: 27-37. 10.1016/j.aaen.2005.10.001.

Bhasale AL, Miller GC, Reid SE, Britt HC: Analysing potential harm in Australian general practice: an incident-monitoring study. MJA. 1998, 169: 73-76.

van Vuuren W, Shea CE, Schaaf van der TW: The development of an incident analysis tool for the medical field. 1997, Eindhoven: Eindhoven University of Technology, [ http://alexandria.tue.nl/repository/books/493452.pdf ]

Schaaf van der TW, Habraken MMP: PRISMA-Medical a brief description. 2005, Eindhoven: Eindhoven University of Technology, Faculty of Technology Management, Patient Safety Systems

World Health Organization Alliance for Patient Safety: Project to develop the international patient safety event taxonomy: updated review of the literature 2003-2005. 2005, Geneva: World Health Organization

World Health Organization Alliance for Patient Safety: The conceptual framework of an international patient safety event classification: executive summary. 2006, Geneva: World Health Organization

Reason JT: Managing the risk of organisational accidents. 1997, Aldershot, UK: Ashgate

Reason JT: Human error. 1990, Cambridge: Cambridge University Press

Rasmussen J: Skills, Rules and Knowledge: Signals, Signs and Symbols and Other Distinctions in Human Performance Models. IEEE Trans Systems Man Cybernetics. 1983, 13: 257-266.

Kaplan HS, Battles JB, Schaaf Van der TW, Shea CE, Mercer SQ: Identification and classification of the causes of events in transfusion medicine. Transfusion. 1998, 38: 1071-1081. 10.1046/j.1537-2995.1998.38111299056319.x.

Smits M, Janssen JCJA, de Vet HCW, Zwaan L, Timmermans DRM, Groenewegen PP, Wagner C: Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. Int J Qual Health Care. 2009, 21: 292-300. 10.1093/intqhc/mzp023.

Federal Aviation Administration: Pilot's Handbook of Aeronautical Knowledge: FAA-H-8083-25. 2003, Washington DC: U.S. Government Printing Office (GPO)

Patient safety program Prevent harm, work safely in Dutch hospitals (in Dutch). 2007, Utrecht: NVZ, Orde van medisch specialisten, LEVV, V&VN, NFU

Reason JT: Understanding adverse events: the human factor. Clinical Risk Management: Enhancing patient safety. Edited by: Vincent C. 2001, London: BMJ Books, 9-30.

Norris B: Human factors and safe patient care. J Nurs Manag. 2009, 17: 203-211. 10.1111/j.1365-2834.2009.00975.x.

Wagner C, Smits M, van Wagtendonk I, Zwaan L, Lubberding S, Merten H, Timmermans DRM: Causes of incidents and adverse events in hospitals: a systematic analysis of incident reports at emergency departments, surgery departments and internal medicine departments (in Dutch). 2008, Amsterdam, Utrecht: EMGO Institute, NIVEL