TY - JOUR
T1 - Examining causes and prevention strategies of adverse events in deceased hospital patients: A retrospective patient record review study in the netherlands
AU - Smits, Marleen
AU - Langelaan, Maaike
AU - de Groot, Janke
AU - Wagner, Cordula
N1 - Funding Information: From the *Nivel, Netherlands Institute for Health Services Research, Utrecht; †Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen; and ‡Department of Public and Occupational Health, Amsterdam Public Health research institute (APH), VU University Medical Center, Amsterdam, the Netherlands. Correspondence: Marleen Smits, PhD, Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, the Netherlands (e‐mail: m.smits@nivel.nl). The study was supported by the Dutch Ministry of Health, Welfare and Sport. The funder had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the article. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.journalpatientsafety.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Publisher Copyright: © 2021 Lippincott Williams and Wilkins. All rights reserved. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.
PY - 2021/6/1
Y1 - 2021/6/1
N2 - Objective: To improve patient safety and possibly prevent mortality from adverse events (AEs) in hospitals, it is important to gain insight in their underlying causes.We aimed to examine root causes and potential prevention strategies of AEs in deceased hospital patients. Methods: Data on 571 AEs were used from two retrospective patient record review studies of patients who died during hospitalization in the Netherlands. Trained reviewers assessed contributing factors and potential prevention strategies. The results were analyzed together with data on preventability of the AE and the relationship of the AE with the death of the patient. Results: In 47% of the AEs, patient-related causes were identified, in 35% human causes, in 9% organizational causes, and in 3% technical causes. Preventable AEs were caused by technical, organizational, and human causes (78%, 74%, and 74%, respectively) more often than by patientrelated causes (33%). In addition, technical factors caused AEs leading to preventable death (78%) relatively often. Recommended strategies to prevent AEswere quality assurance/peer review, evaluation of safety behavior, improving procedures, and improving information and communication structures. Conclusions: Human failures played an important role in the causation of AEs in Dutch hospitals, because they occurred frequently and they were frequently the cause of preventable AEs. To a lesser extent, latent organizational and technical factors were identified. Patient-related factors were often identified, but the preventability of the AEs with these causes was low. For future research into causes of AEs, we recommend combining record review with interviewing.
AB - Objective: To improve patient safety and possibly prevent mortality from adverse events (AEs) in hospitals, it is important to gain insight in their underlying causes.We aimed to examine root causes and potential prevention strategies of AEs in deceased hospital patients. Methods: Data on 571 AEs were used from two retrospective patient record review studies of patients who died during hospitalization in the Netherlands. Trained reviewers assessed contributing factors and potential prevention strategies. The results were analyzed together with data on preventability of the AE and the relationship of the AE with the death of the patient. Results: In 47% of the AEs, patient-related causes were identified, in 35% human causes, in 9% organizational causes, and in 3% technical causes. Preventable AEs were caused by technical, organizational, and human causes (78%, 74%, and 74%, respectively) more often than by patientrelated causes (33%). In addition, technical factors caused AEs leading to preventable death (78%) relatively often. Recommended strategies to prevent AEswere quality assurance/peer review, evaluation of safety behavior, improving procedures, and improving information and communication structures. Conclusions: Human failures played an important role in the causation of AEs in Dutch hospitals, because they occurred frequently and they were frequently the cause of preventable AEs. To a lesser extent, latent organizational and technical factors were identified. Patient-related factors were often identified, but the preventability of the AEs with these causes was low. For future research into causes of AEs, we recommend combining record review with interviewing.
KW - Adverse event
KW - Cause
KW - Hospital
KW - Prevention
KW - Record review
UR - http://www.scopus.com/inward/record.url?scp=85107082434&partnerID=8YFLogxK
U2 - https://doi.org/10.1097/PTS.0000000000000586
DO - https://doi.org/10.1097/PTS.0000000000000586
M3 - Review article
C2 - 30896559
SN - 1549-8425
VL - 17
SP - 282
EP - 289
JO - Journal of patient safety
JF - Journal of patient safety
IS - 4
ER -