Patient Safety and Quality

Hospitalized patients can help improve patient safety by identifying medical errors not captured by hospital systems

Engaging hospitalized patients as partners to help identify medical errors and injuries is a potentially promising approach for enhancing patient safety, suggests a study supported by the Agency for Healthcare Research and Quality (HS11644). Saul N. Weingart, M.D., Ph.D., of Harvard Medical School, and colleagues interviewed 264 patients who were hospitalized at a Boston teaching hospital about adverse events (ADEs), including any problems, mistakes, or injuries that occurred during their hospital stay.

Among 228 patients admitted to the medical unit, the patient-reported ADE rate was nearly 9 per 100 admissions, with problems ranging from medication errors to falls, delayed provision of compression bandages, and nonprocessed laboratory samples. Serious injuries were uncommon, but two-thirds were judged preventable. Overall, 17 patients (8 percent) reported 20 ADEs, 1 of them serious. Eight patients (4 percent) reported 13 near misses, 5 of which were serious or life threatening.

Fifty-five percent of ADEs and 31 percent of near misses were documented in the medical records of these patients, yet none was submitted by clinicians to the hospital's incident reporting system. Patients with three or more drug allergies were more likely to report errors than patients without drug allergies. Also, patients on multiple medications were more likely to report adverse events, which is consistent with the link between ADEs and polypharmacy in nursing home and primary care settings.

The researchers suggest that patients and their families who identify errors and injuries or conditions that increase the risk of harm are a potentially useful source of information that can be used to guide patient safety improvement efforts.

See "What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents," by Dr. Weingart, Odelya Pagovich, B.A., Daniel Z. Sands, M.D., M.P.H., and others, in the September 2005 Journal of General Internal Medicine 20, pp. 830-836.

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