Slide Presentation of the 2007 Annual Meeting of AHRQ

Questionnaire Content—2 Safety Events

• Adverse Events
  • "About how many adverse events affecting patient(s) under your care occurred in the last week?"
  • ."..about how many were due to a mistake for which you felt at least partly responsible?"
  • "About how many times in the last week was there a near miss or close call for which you felt at least partly responsible?"
• Medical Error = Near miss or AE due to mistake

Notes:

Adverse events
"A complication, injury, or harm to a patient resulting from medical management (not from the patient's underlying condition or disease). An adverse event may or may not be preventable (i.e., due to a mistake). Some examples include pneumothorax, retained objects, and adverse drug reactions, as well as hospital acquired infections, decubitis ulcers, peri-operative MIs, line infections, and falls."
Mistakes
"A mistake is an act or omission by any caregiver which would have been judged wrong by knowledgeable peers at the time it occurred."
Near-misses (close-calls)
"A near-miss or close-call is a mistake that does not reach the patient or if it reaches the patient does not result in injury or harm."