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Adverse events in primary care identified from a risk-management database
G Fischer1, M D Fetters, A P Munro
1University of Rochester, New York, USA.
The Journal of Family Practice
|July 1, 1997
Summary
Adverse events in primary care are infrequent but often preventable, with medical errors causing most harm. Improving systems for tracking and analyzing these events is crucial for patient safety.
Area of Science:
- Medical Risk Management
- Patient Safety
- Primary Health Care
Background:
- Adverse events in medicine stem from various factors including human error and inherent risks.
- Understanding adverse events is key to reducing their incidence and impact.
- This study examines adverse events in an outpatient primary care setting.
Purpose of the Study:
- To describe adverse events identified in a primary care setting.
- To analyze the causes, preventability, and outcomes of these events.
Main Methods:
- Reviewed incident reports from an academic medical center's risk-management database (1991-1996).
- Included reports from eight affiliated primary health care clinics.
- Two independent reviewers assessed incidents for adverse medical events and analyzed their causes, preventability, and outcomes.
Main Results:
- Prevalence of adverse events was 3.7 per 100,000 clinic visits.
- 83% of adverse events were due to preventable medical errors.
- Causes included diagnostic (26%), treatment (31%), and other errors (26%).
- 14% of medical error-related events caused permanent injury; 3% resulted in death.
Conclusions:
- Serious adverse events are infrequent in primary care but likely underestimated.
- Enhanced systems for recognizing, tracking, and analyzing adverse events are needed.
- Improving these systems can help reduce or prevent adverse events in primary care.