Marieke Zegers

Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study

Objective: This study determined the incidence, type, nature, preventability and impact of adverse events (AEs) among hospitalised patients and potentially preventable deaths in Dutch hospitals. Methods: Using a three-stage retrospective record review process, trained nurses and doctors reviewed 7926 admissions: 3983 admissions of deceased hospital patients and 3943 admissions of discharged patients in 2004, in a random sample of 21 hospitals in the Netherlands (4 university, 6 tertiary teaching and 11 general hospitals). A large sample of deceased patients was included to determine the occurrence of potentially preventable deaths in hospitals more precisely. Results: One or more AEs were found in 5.7% (95% CI 5.1% to 6.4%) of all admissions and a preventable AE in 2.3% (95% CI 1.9% to 2.7%). Of all AEs, 12.8% resulted in permanent disability or contributed to death. The proportion of AEs and their impact increased with age. More than 50% of the AEs were related to surgical procedures. Among deceased hospital patients, 10.7% (95% CI 9.8% to 11.7%) had experienced an AE. Preventable AEs that contributed to death occurred in 4.1% (95% CI 3.5% to 4.8%) of all hospital deaths. Extrapolating to a national level, between 1482 and 2032 potentially preventable deaths occurred in Dutch hospitals in 2004. Conclusions: The incidence of AEs, preventable AEs and potentially preventable deaths in the Netherlands is substantial and needs to be reduced. Patient safety efforts should focus on surgical procedures and older patients.

Design of a retrospective patient record study on the occurrence of adverse events among patients in Dutch hospitals.

BackgroundVarious international studies have shown that a substantial number of patients suffer from injuries or even die as a result of care delivered in hospitals. The occurrence of injuries among patients caused by health care management in Dutch hospitals has never been studied systematically. Therefore, an epidemiological study was initiated to determine the incidence, type and impact of adverse events among discharged and deceased patients in Dutch hospitals.Methods/DesignThree stage retrospective patient record review study in 21 hospitals of 8400 patient records of discharged or deceased patients in 2004. The records were reviewed by trained nurses and physicians between August 2005 and October 2006. In addition to the determination of presence, the degree of preventability, and causes of adverse events, also location, timing, classification, and most responsible specialty of the adverse events were measured. Moreover, patient and admission characteristics and the quality of the patient records were recorded.DiscussionIn this paper we report on the design of the retrospective patient record study on the occurrence of adverse events in Dutch hospitals. Attention is paid to the strengths and limitations of the study design. Furthermore, alterations made in the original research protocol in comparison with former international studies are described in detail.

Direct medical costs of adverse events in Dutch hospitals

BackgroundUp to now, costs attributable to adverse events (AEs) and preventable AEs in the Netherlands were unknown. We assessed the total direct medical costs associated with AEs and preventable AEs in Dutch hospitals to gain insight in opportunities for cost savings.MethodsTrained nurses and physicians retrospectively reviewed 7926 patient records in 21 hospitals. Additional patient information of 7889 patients was received from the Dutch registration of hospital information. Direct medical costs attributable to AEs were assessed by measuring excess length of stay and additional medical procedures after an AE occurred. Costs were valued using Dutch standardized cost prices.ResultsThe annual direct medical costs in Dutch hospitals were estimated at a total of euro 355 million for all AEs and euro 161 million for preventable AEs in 2004. The total number of hospital admissions in which a preventable AE occurred was 30,000 (2.3% of all admissions) and more than 300,000 (over 3% of all bed days) bed days were attributable to preventable AEs in 2004. Multilevel analysis showed that variance in direct medical costs was not determined by differences between hospitals or hospital departments.ConclusionThe estimates of the total preventable direct medical costs of AEs indicate that they form a substantial part (1%) of the expenses of the national health care budget and are of importance to hospital management. The cost driver of the direct medical costs is the excess length of stay (including readmissions) in a hospital. Insight in which determinants are associated with high preventable costs will offer useful information for policymakers and hospital management to determine starting points for interventions to reduce the costs of preventable AEs.

The inter-rater agreement of retrospective assessments of adverse events does not improve with two reviewers per patient record

OBJECTIVE To evaluate the inter-rater agreement of the record review process of the Dutch Adverse Event study, which we aimed to improve by the involvement of two independent physician reviewers per record instead of one including a consensus procedure in case of disagreement. METHODS The inter-rater agreement within pairs of physicians (independent review between physician A+B) and between pairs of physicians (independent review between physician A+B and C+D) was measured to evaluate the record review process with two physicians including a consensus procedure, with 4,272 and 119 records, respectively. RESULTS The inter-rater agreement within pairs of physicians was substantial for the determination of adverse events (AEs) with a kappa of 0.64 (95% confidence interval [CI]: 0.61, 0.68). The inter-rater agreement between pairs of physicians was fair for the determination of AEs with a kappa of 0.25 (95% CI: 0.05, 0.45). CONCLUSION A record review process with two physicians per record including a consensus procedure to assess AEs is not more reliable than a record review process with one physician. Retrospective estimates of incidence of AEs from record review studies should be interpreted with caution. Improvement of the method is necessary for monitoring incidence of AEs over time at a national level.

The incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies

BackgroundWe need to know the scale and underlying causes of surgical adverse events (AEs) in order to improve the safety of care in surgical units. However, there is little recent data. Previous record review studies that reported on surgical AEs in detail are now more than ten years old. Since then surgical technology and quality assurance have changed rapidly. The objective of this study was to provide more recent data on the incidence, consequences, preventability, causes and potential strategies to prevent AEs among hospitalized patients in surgical units.MethodsA structured record review study of 7,926 patient records was carried out by trained nurses and medical specialist reviewers in 21 Dutch hospitals. The aim was to determine the presence of AEs during hospitalizations in 2004 and to consider how far they could be prevented. Of all AEs, the consequences, responsible medical specialty, causes and potential prevention strategies were identified. Surgical AEs were defined as AEs attributable to surgical treatment and care processes and were selected for analysis in detail.ResultsSurgical AEs occurred in 3.6% of hospital admissions and represented 65% of all AEs. Forty-one percent of the surgical AEs was considered to be preventable. The consequences of surgical AEs were more severe than for other types of AEs, resulting in more permanent disability, extra treatment, prolonged hospital stay, unplanned readmissions and extra outpatient visits. Almost 40% of the surgical AEs were infections, 23% bleeding, and 22% injury by mechanical, physical or chemical cause. Human factors were involved in the causation of 65% of surgical AEs and were considered to be preventable through quality assurance and training.ConclusionsSurgical AEs occur more often than other types of AEs, are more often preventable and their consequences are more severe. Therefore, surgical AEs have a major impact on the burden of AEs during hospitalizations. These findings concur with the results from previous studies. However, evidence-based solutions to reduce surgical AEs are increasingly available. Interventions directed at human causes are recommended to improve the safety of surgical care. Examples are team training and the surgical safety checklist. In addition, specific strategies are needed to improve appropriate use of antibiotic prophylaxis and sustainable implementation of hygiene guidelines to reduce infections.

Quality of patient record keeping: an indicator of the quality of care?

Background Patient record review of hospitalised patients is by far the most applied method to assess adverse events (AEs) in hospitals. The diligence with which information is recorded may influence the visibility of AEs. On the other hand, poor quality of the information in patient records may be a cause or a consequence of poor quality of care and may thus be associated with higher rates of AEs. The objective of this study was to assess the relation between the quality of patient records and the occurrence of AEs. Methods In this study, 7926 hospital admissions of 21 Dutch hospitals were analysed with a structured record review method. The occurrence of AEs, the presence of patient information and the quality of the present information (completeness, readability and adequacy) were assessed. Their association was analysed using multilevel logistic regression analyses. Results The absence of record components was associated with lower rates of AEs, suggesting that missing record components lead to an underassessment of AEs in record-review studies. In contrast, poor quality of the information present in patient records was associated with higher rates of AEs, implying that the quality of the present patient information is a predictor of the quality of care. Conclusions Evidence-based standards and a (electronic) format for record keeping are necessary for standardisation of recording patient information. This will improve the completeness, readability, accessibility, accuracy and exchange of patient information between healthcare providers and institutions. Better registration of patient information will benefit the quality of the healthcare process and will reduce the risk of AEs.

Exploring the causes of adverse events in hospitals and potential prevention strategies

Objectives To examine the causes of adverse events (AEs) and potential prevention strategies to minimise the occurrence of AEs in hospitalised patients. Methods For the 744 AEs identified in the patient record review study in 21 Dutch hospitals, trained reviewers were asked to select all causal factors that contributed to the AE. The results were analysed together with data on preventability and consequences of AEs. In addition, the reviewers selected one or more prevention strategies for each preventable AE. The recommended prevention strategies were analysed together with four general causal categories: technical, human, organisational and patient-related factors. Results Human causes were predominantly involved in the causation of AEs (in 61% of the AEs), 61% of those being preventable and 13% leading to permanent disability. In 39% of the AEs, patient-related factors were involved, in 14% organisational factors and in 4% technical factors. Organisational causes contributed relatively often to preventable AEs (93%) and AEs resulting in permanent disability (20%). Recommended strategies to prevent AEs were quality assurance/peer review, evaluation of safety behaviour, training and procedures. For the AEs with human and patient-related causes, reviewers predominantly recommended quality assurance/peer review. AEs caused by organisational factors were considered preventable by improving procedures. Discussion Healthcare interventions directed at human causes are recommended because these play a large role in AE causation. In addition, it seems worthwhile to direct interventions on organisational causes because the AEs they cause are nearly always believed to be preventable. Organisational factors are thus relatively easy to tackle. Future research designs should allow researchers to interview healthcare providers that were involved in the event, as an additional source of information on contributing factors.

Improving patient discharge and reducing hospital readmissions by using Intervention Mapping

BackgroundThere is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge.MethodsThe Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance.ResultsIneffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change.ConclusionsThis study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care.

Medication reconciliation at hospital admission and discharge: insufficient knowledge, unclear task reallocation and lack of collaboration as major barriers to medication safety.

BackgroundMedication errors are a leading cause of patient harm. Many of these errors result from an incomplete overview of medication either at a patient’s referral to or at discharge from the hospital. One solution is medication reconciliation, a formal process in which health care professionals partner with patients to ensure an accurate and complete transfer of medication information at interfaces of care. In 2007, the Dutch government compelled hospitals to implement a bundle concerning medication reconciliation at hospital admission and discharge. But to date many hospitals have failed to implement this bundle fully. The aim of this study was to gain insight into the barriers and drivers of the implementation process.MethodsWe performed face to face, semi-structured interviews with twenty health care professionals and managers from several departments at a 953 bed university hospital in the Netherlands and also from the surrounding community health services. The interviews were analysed using a combined theoretical framework of Grol and Cabana to classify the drivers and barriers identified.ResultsThere is lack of awareness and insufficient knowledge of health care professionals about the health care problem and the bundle medication reconciliation. These result in a lack of support for implementing the bundle. In addition clinicians are reluctant to reallocate tasks to nurses or pharmacy technicians. Another major barrier is a lack of communication, understanding and collaboration between hospital and community caregivers. The introduction of more competitive market forces has made matters worse. Major drivers are a good implementation plan, patient awareness, and obligation by the government.ConclusionsWe identified a wide range of barriers and drivers which health care professionals believe influence the implementation of medication reconciliation. This reflects the complexity of implementation. Implementation can be improved if these factors are adequately addressed. The feasibility and effectiveness of these strategies should be tested in controlled trails.

Variation in the rates of adverse events between hospitals and hospital departments

OBJECTIVE The objective of this study was to analyze the variation in the rates of adverse events (AEs), and preventable AEs, between hospitals and hospital departments in order to investigate the room for improvement in reducing AEs at both levels. In addition, we explored the extent to which patient, department and hospital characteristics explain differences in the rates of AEs. DESIGN Structured retrospective patient record review of hospital admissions. SETTING Twenty-one Dutch hospitals. Population A representative random sample of 7113 hospital admissions in 2004. MAIN OUTCOME MEASURES Variation in AEs, and preventable AEs, between hospitals and hospital departments and the explanatory factors of the variation. RESULTS The rates of AEs varied between hospitals (P = 0.05) and hospital departments (P < 0.05). The rates of preventable AEs only varied significantly between hospital departments. The clustering of preventable AEs in hospital departments was more than twice that found in hospitals (ICC 9.5 versus 3.5%). The type of hospital explained 35% of the inter-hospital variance in AEs. Patient and department characteristics explained 23% of the inter-department variance in preventable AEs. CONCLUSIONS In addition to interventions to improve the overall patient safety within a hospital, interventions tailored for specific departments are necessary to reduce their patient safety risks. Monitoring and comparing the performance of hospitals should not be limited to the hospital level, but should be extended to the individual department since there can be significant differences in the rates of preventable AEs between different departments within the same hospital.