Epidemiology of medical adverse events: perspectives from a single institute in Taiwan

Wang, Chen-Hsu; Shih, Chung-Liang; Chen, Wenjing; Hung, Sheng-Hui; Jhang, Wei-Jia; Chuang, Li-Ju; Wang, Pa‐Chun

doi:10.1016/j.jfma.2015.11.004

Cited by 9 publications

(9 citation statements)

References 12 publications

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“…Thus, the results point mainly to the need for review/improvement of the operative technique and are consistent with the findings of another Brazilian study, which pointed out 27% (n = 7) of technical failures in a surgical center 21 , in the same way as in a medical center in China, in which a study showed 61.6% (n = 16) of AEs related to technical and/or surveillance failures 22 .…”

Section: Discussionsupporting

confidence: 88%

Prevalência e evitabilidade de eventos adversos cirúrgicos em hospital de ensino do Brasil

Batista

Cruz

Alpendre

et al. 2019

Rev. Latino-Am. Enfermagem

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Objective to estimate the prevalence and avoidability of surgical adverse events in a teaching hospital and to classify the events according to the type of incident and degree of damage.Method cross-sectional retrospective study carried out in two phases. In phase I, nurses performed a retrospective review on a simple randomized sample of 192 records of adult patients using the Canadian Adverse Events Study form for case tracking. Phase II aimed at confirming the adverse event by an expert committee composed of physicians and nurses. Data were analyzed by univariate descriptive statistics.Results the prevalence of surgical adverse events was 21.8%. In 52.4% of the cases, detection occurred on outpatient return. Of the 60 cases analyzed, 90% (n = 54) were preventable and more than two thirds resulted in mild to moderate damage. Surgical technical failures contributed in approximately 40% of the cases. There was a prevalence of the infection category associated with health care (50%, n = 30). Adverse events were mostly related to surgical site infection (30%, n = 18), suture dehiscence (16.7%, n = 10) and hematoma/seroma (15%, n = 9).Conclusion the prevalence and avoidability of surgical adverse events are challenges faced by hospital management.

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Section: Discussionsupporting

confidence: 88%

Prevalência e evitabilidade de eventos adversos cirúrgicos em hospital de ensino do Brasil

Batista

Cruz

Alpendre

et al. 2019

Rev. Latino-Am. Enfermagem

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“…A certain level of bias in judging single cases cannot be excluded and might also increase the number of AEs found. Internationally preventability of AEs ranges from 43 to 70% ( Wang et al, 2016 , Aranaz-Andres et al, 2008 , von Laue et al, 2003 ). This indicates that there are considerable differences in the way judgments about preventability, or even the presence of an AE, are made.…”

Section: Discussionmentioning

confidence: 99%

The ability of triggers to retrospectively predict potentially preventable adverse events in a sample of deceased patients

Klein

Rennenberg

Koopmans

et al. 2017

Preventive Medicine Reports

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Several trigger systems have been developed to screen medical records of hospitalized patients for adverse events (AEs). Because it's too labor-intensive to screen the records of all patients, usually a sample is screened. Our sample consists of patients who died during their stay because chances of finding preventable AEs in this subset are highest.Records were reviewed for fifteen triggers (n = 2182). When a trigger was present, the records were scrutinized by specialized medical doctors who searched for AEs. The positive predictive value (PPV) of the total trigger system and of the individual triggers was calculated. Additional analyses were performed to identify a possible optimization of the trigger system.In our sample, the trigger system had an overall PPV for AEs of 47%, 17% for potentially preventable AEs. More triggers present in a record increased the probability of detecting an AE. Adjustments to the trigger system slightly increased the positive predictive value but missed about 10% of the AEs detected with the original system.In our sample of deceased patients the trigger system has a PPV comparable to other samples. However still, an enormous amount of time and resources are spent on cases without AEs or with non-preventable AEs. Possibly, the performance could be further improved by combining triggers with clinical scores and laboratory results. This could be promising in reducing the costly and labor-intensive work of screening medical records.

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“…Patient safety management involves reduction of patient harm from potentially avoidable unintended outcomes. Studies have revealed that many adverse medical events (AMEs) are preventable 1 ; hence, to eliminate such errors, appropriate management of AMEs becomes the cornerstone of patient safety work. Through incident reporting, investigation, and analysis, health care providers can correct or reengineer their care processes to prevent incident recurrence.…”

Section: Letter To the Editormentioning

confidence: 99%

Human Factor Consideration in Routine Root Cause Analysis

Cheng¹,

Hung²,

Ko³

et al. 2020

American Journal of Medical Quality

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Epidemiology of medical adverse events: perspectives from a single institute in Taiwan

Abstract: Surgical patients with cardiac conditions were at risk of MAE, particularly patients who received invasive procedures. The epidemiology information from this study can serve as baseline data to monitor a patient safety improvement campaign.

Cited by 9 publications

References 12 publications

Prevalência e evitabilidade de eventos adversos cirúrgicos em hospital de ensino do Brasil

Prevalência e evitabilidade de eventos adversos cirúrgicos em hospital de ensino do Brasil

The ability of triggers to retrospectively predict potentially preventable adverse events in a sample of deceased patients

Human Factor Consideration in Routine Root Cause Analysis

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