Setting priorities for patient safety

Current "flags" for adverse events (AEs) are biased towards those with serious outcomes, potentially leading to failure to address mundane common problems.

To provide a basis for setting priorities to improve patient safety by ranking adverse events by resource consumption as well as by outcome. This was done by classifying a set of AEs, according to how they may be prevented, into "Principal Natural Categories" (PNCs).

AEs associated with a representative sample of admissions to Australian acute care hospitals.

AEs were classified into PNCs which were ranked by overall frequency, an index of resource consumption (a function of mean extended hospital stay and the number of cases in each PNC), and severity of outcome.

The 1712 AEs analysed fell into 581 PNCs; only 28% had more than two cases. Most resource use (60%) was by AEs which led to minor disabilities, 36% was by those which led to major disabilities, and 4% by those associated with death. Most of the events with serious outcomes fell into fewer than 50 PNCs; only seven of these PNCs had more than six cases resulting in serious outcomes.

If interventions for AEs are triggered only by serious outcomes by, for example, using recommended risk scoring methods, most problems would not be addressed, particularly the large number of mundane problems which consume the majority of resources. Both serious and mundane problems should be addressed. Most types of events occur too infrequently to be characterised at a hospital level and require large scale (preferably national) collections of incidents and events.