Detecting adverse events for patient safety research: a review of current methodologies <s> Prompted spontaneous reporting <s> OBJECTIVE ::: To assess the effectiveness of housestaff physician reporting as a method for identifying adverse events on a medical service and to compare the physician reporting mechanism with a retrospective record review mechanism. ::: ::: ::: SETTING ::: Medical service of an urban, university-affiliated teaching hospital. ::: ::: ::: DESIGN ::: Concurrent physician reporting mechanism using the hospital electronic mail system compared with a retrospective record review using a screening mechanism followed by structured, implicit physician review of the record. ::: ::: ::: PATIENTS ::: All 3146 admissions to the medical service from 13 November 1990 to 14 March 1991. ::: ::: ::: RESULTS ::: The housestaff physician reporting method identified nearly the same number (89) of adverse events as did the record review (85). However, the two methods identified only 41 of the same patients (kappa = 0.52). No statistically significant clinical or socioeconomic differences occurred between the patients identified as having had an adverse event, using the two reporting methods (physician versus record review). The housestaff did report statistically more preventable adverse events (62.5% compared with 32%; P = 0.003). The physician reporting mechanism was also less costly (approximately $15,000 compared with $54,000). ::: ::: ::: CONCLUSION ::: An adverse event identification strategy based on physician self-referral uncovers as many adverse events as does a record review and is less costly. In addition, physician-identified events are more likely to be preventable and, thus, are targets for quality improvement. <s> BIB001 </s> Detecting adverse events for patient safety research: a review of current methodologies <s> Prompted spontaneous reporting <s> OBJECTIVES ::: To assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. To analyze preventable events to develop prevention strategies. ::: ::: ::: DESIGN ::: Prospective cohort study. ::: ::: ::: PARTICIPANTS ::: All 4031 adult admissions to a stratified random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical intensive care units and four medical and two surgical general care units. ::: ::: ::: MAIN OUTCOME MEASURES ::: Adverse drug events and potential ADEs. ::: ::: ::: METHODS ::: Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented ADEs or potential ADEs and as to severity and preventability. ::: ::: ::: RESULTS ::: Over 6 months, 247 ADEs and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 nonobstetrical admissions, for mean numbers per hospital per year of approximately 1900 ADEs and 1600 potential ADEs. Of all ADEs, 1% were fatal (none preventable), 12% life-threatening, 30% serious, and 57% significant. Twenty-eight percent were judged preventable. Of the life-threatening and serious ADEs, 42% were preventable, compared with 18% of significant ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. Errors were much more likely to be intercepted if the error occurred earlier in the process: 48% at the ordering stage vs 0% at the administration stage. ::: ::: ::: CONCLUSION ::: Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process. <s> BIB002 </s> Detecting adverse events for patient safety research: a review of current methodologies <s> Prompted spontaneous reporting <s> OBJECTIVE ::: To determine whether or not prompting of medical residents at morning report enhances reporting of adverse events in hospitalized patients. ::: ::: ::: DESIGN ::: Prospective trial comparing 3-month blocks of intensive prompting, modest prompting, and no prompting on adverse event reporting by housestaff at morning report. ::: ::: ::: SETTING ::: Inpatient internal medicine service at a university-affiliated, Veterans Affairs Medical Center teaching hospital. ::: ::: ::: INTERVENTIONS ::: Intensive prompting (daily), modest prompting (once or twice weekly), and no prompting of medical residents to report hospital-associated adverse events. ::: ::: ::: MEASUREMENTS AND MAIN RESULTS ::: The number, type, and severity of hospital-acquired adverse events occurring on an internal medicine service were determined during the various periods of intervention on a per houseofficer basis. Residents were reminded to record events once or twice weekly, daily, or not at all. These data were compared with those identified by usual hospital surveillance. The addition of housestaff reporting to usual hospital surveillance increased the numbers of adverse events reported. There was little overlap in episodes reported by the two strategies. Increasing the level of prompting increased the number of reports per houseofficer. Housestaff prompting increased reporting at all levels of adverse event severity from mild to serious and detected a wide variety of types of adverse events, especially adverse drug reactions and procedure complications. ::: ::: ::: CONCLUSIONS ::: Our study demonstrates that physician self-reporting of adverse events adds to the usual hospital surveillance adverse event reporting, and finds that such reporting can be easily accomplished within the context of a daily teaching activity. The information provided about adverse events by housestaff at morning report is additive to that obtained by usual surveillance methods. The use of such a strategy provides information in a timely fashion. <s> BIB003 </s> Detecting adverse events for patient safety research: a review of current methodologies <s> Prompted spontaneous reporting <s> OBJECTIVE: To evaluate the frequency of medication errors using a multidisciplinary approach, to classify these errors by type, and to determine how often medication errors are associated with adverse drug events (ADEs) and potential ADEs. <s> BIB004
Some investigators have attempted to increase voluntary reporting through continuously prompting physicians, nurses, or pharmacists to report errors or adverse events. In one study, medical residents were sent daily electronic mail reminder reminding them to report adverse events BIB001 . Along with the daily prompts, once weekly all medical residents were again asked to report adverse events. Adverse events were reported through either electronic mail or paper reports. Over the fourmonth study period the residents reported 89 adverse events while 85 were detected by chart review. Notably, only 41 of the adverse events were identified by both of the methodologies, although all the adverse events appeared real, suggesting that the true underlying rate is higher than that identified by any single methodology. Welsh et al. BIB003 studied how the intensity of prompted reporting might influence reporting rates. Medical residents who were prompted on a daily basis tended to report more adverse events per month (55 AE 4) when compared to those prompted weekly (24 AE 15) or those not prompted at all (21 AE 2). Furthermore, the number of housestaff reporting adverse events increased as the intensity of prompting increased (no prompting ¼ 0.55 AE 0.3, low-level prompting ¼ 1.47 AE 0.3, intensive-level prompting ¼ 4.04 AE 0.4, p < 0:001). Similar to prior studies, the degree of overlap between events reported by the residents and those detected through incident reporting was small. Another study created a voluntary reporting system in which residents detected adverse events by interviews with their peers and detected 88 adverse events over a 3-month period  . This study, as prior studies of prompted physician report, has several limitations. The intervention was only studied over a short period of time, and it is unclear if because of the high level of effort required maintaining these systems they could be sustainable. Furthermore, these studies have targeted medical residents only. Not only might prompted physician reporting not improve adverse event detection rates for hospitals without residents, but also these methods might not even be effective for non-medical housestaff, such as surgical or obstetric residents. Stimulated voluntary reporting has also been used with nurses and pharmacists BIB004 BIB002 . In these studies, nurses and pharmacists were asked on each shift whether they had noted anything that might represent an adverse drug event or potential adverse drug event. Overall, this approach was much more effective for identifying near misses than adverse events.