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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.
Background:
The inevitability of adverse events in medicine arises from human fallibility, negligent care, limits of medical knowledge, risks inherent in medical practice, and biological variability among individuals. A better understanding of the nature and causes of adverse events is necessary to reduce their occurrence and limit their harm. This study describes adverse events identified from a risk-management database that occurred in an out-patient primary care setting.
Methods:
Incident reports filed with the risk-management office of an academic medical center between January 1, 1991, and June 30, 1996, by eight primary health care clinics affiliated with the center were eligible for the study. Two independent reviewers assessed the incidents to determine whether there were adverse medical events. Incidents classified as adverse events were analyzed to determine the cause, potential preventability, and outcome.
Results:
The prevalence of adverse events was 3.7 per 100,000 clinic visits over a period of 5 1/2 years. Twenty-nine of 35 (83%) adverse events were due to medical errors and were considered preventable. The causes of the adverse events included 9 diagnostic errors (26%), 11 treatment errors (31%), and 9 other errors (26%). Of the adverse events attributed to medical errors, 4 (14%) resulted in a permanent, disabling injury and 1 (3%) resulted in a death.
Conclusions:
Serious adverse events appear to occur infrequently in primary care outpatient practice, although these data probably underestimate the overall prevalence. To reduce or prevent the occurrence of adverse events in primary care, better systems for recognizing and tracking them and for assessing their causes are needed.
Insights
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.