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Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Health and Developmental Care, Patient Safety.
Östergötlands Läns Landsting, Center for Health and Developmental Care, Center for Public Health.
Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
Östergötlands Läns Landsting, Center for Health and Developmental Care, Patient Safety.
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2014 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 4, no 5, 004879- p.Article in journal (Refereed) Published
Abstract [en]

Objectives: To describe the level, preventability and categories of adverse events (AEs) identified by medical record review using the Global Trigger Tool (GTT). To estimate when the AE occurred in the course of the hospital stay and to compare voluntary AE reporting with medical record reviewing. Design: Two-stage retrospective record review. Setting: 650-bed university hospital. Participants: 20 randomly selected medical records were reviewed every month from 2009 to 2012. Primary and secondary outcome measures: AE/1000 patient-days. Proportion of AEs found by GTT found also in the voluntary reporting system. AE categorisation. Description of when during hospital stay AEs occur. Results: A total of 271 AEs were detected in the 960 medical records reviewed, corresponding to 33.2 AEs/1000 patient-days or 20.5% of the patients. Of the AEs, 6.3% were reported in the voluntary AE reporting system. Hospital-acquired infections were the most common AE category. The AEs occurred and were detected during the hospital stay in 65.5% of cases; the rest occurred or were detected within 30 days before or after the hospital stay. The AE usually occurred early during the hospital stay, and the hospital stay was 5 days longer on average for patients with an AE. Conclusions: Record reviewing identified AEs to a much larger extent than voluntary AE reporting. Healthcare organisations should consider using a portfolio of tools to gain a comprehensive picture of AEs. Substantial costs could be saved if AEs were prevented.

Place, publisher, year, edition, pages
BMJ Publishing Group: Open Access / BMJ Journals , 2014. Vol. 4, no 5, 004879- p.
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Medical and Health Sciences
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URN: urn:nbn:se:liu:diva-108944DOI: 10.1136/bmjopen-2014-004879ISI: 000336976900075OAI: oai:DiVA.org:liu-108944DiVA: diva2:734182
Available from: 2014-07-15 Created: 2014-07-13 Last updated: 2017-12-05

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Rutberg, HansSjödahl, RuneNilsson, Lena
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Division of Health Care AnalysisFaculty of Health SciencesPatient SafetyCenter for Public HealthDivision of Clinical SciencesDepartment of Surgery in LinköpingDivision of Drug ResearchDepartment of Anaesthesiology and Intensive Care in Linköping
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