RT Journal Article
SR Electronic
T1 Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital
JF Canadian Medical Association Journal
JO CMAJ
FD Canadian Medical Association
SP 1235
OP 1240
DO 10.1503/cmaj.1030683
VO 170
IS 8
A1 Alan J. Forster
A1 Tim R. Asmis
A1 Heather D. Clark
A1 Ghiath Al Saied
A1 Catherine C. Code
A1 Sharon C. Caughey
A1 Kevin Baker
A1 James Watters
A1 Jim Worthington
A1 Carl van Walraven
YR 2004
UL http://www.cmaj.ca/content/170/8/1235.abstract
AB Background: Adverse events are poor patient outcomes that are due to medical care. Studies of hospital patients have demonstrated that adverse events are common, but few data describe the timing of them in relation to hospital admission. We evaluated characteristics of adverse events affecting patients admitted to a Canadian teaching hospital, paying particular attention to timing. Methods: We randomly selected 502 adults admitted to the Ottawa Hospital for acute care of nonpsychiatric illnesses over a 1-year period. Charts were reviewed in 2 stages. If an adverse event was judged to have occurred, a physician determined whether it occurred before or during the index hospitalization. The reviewer also rated the preventability, severity and type of each adverse event. Results: Of the 64 patients with an adverse event (incidence 12.7%, 95% confidence interval [CI] 10.1%–16.0%), 24 had a preventable event (4.8%, 95% CI 3.2%–7.0%), and 3 (0.6%, 95% CI 0.2%–1.7%) died because of an adverse event. Most adverse events were due to drug treatment, operative complications or nosocomial infections. Of the 64 patients, 39 (61%, 95% CI 49%–72%) experienced the adverse event before the index hospitalization. Interpretation: Adverse events were common in this study. However, only one-third were deemed avoidable, and most occurred before the hospitalization. Interventions to improve safety must address ambulatory care as well as hospital-based care.