Background. Adverse events during hospitalization are a major cause of patient harm, as documented in the 1991 Harvard Medical Practice Study. Patient safety has changed substantially in the decades since that study was conducted, and a more current assessment of harm during hospitalization is warranted. Methods. We conducted a retrospective cohort study to assess the frequency, preventability, and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during the 2018 calendar year. The occurrence of adverse events was assessed with the use of a trigger method (identification of information in a medical record that was previously shown to be associated with adverse events) and from review of medical records. Trained nurses reviewed records and identified admissions with possible adverse events that were then adjudicated by physicians, who confirmed the presence and characteristics of the adverse events. Results. In a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%). There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care – associated infections (11.9%). Conclusions. Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement. (Funded by the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.)
Commentaire du Dr Marius Laurent (PAQS)
- Le fait d’être interrompu dans une tâche est susceptible d’en altérer l’exécution. La question a été explorée dans des procédures très spécifiques, en particulier lors de l’administration de médicaments, ou de préparation de dilutions en pédiatrie. En est-il de même dans le processus du diagnostic ? Les auteurs font tout d’abord une revue de ce qui est publié, et qui n’est pas clairement conclusif : le processus diagnostique est souvent étalé dans le temps. En dehors de situations urgentes, il peut prendre des jours. Les études expérimentales existantes se sont adressées à des processus courts, et ont étudié des interruptions touchant la mémoire à court terme (répéter un groupe de chiffres) ou à long terme (répondre à un choix multiple), sans forcément déceler de dégradation des performances [1]. L’auteur fait le tour des stratégies possibles pour éviter les interruptions (par exemple celles générées par les alertes diverses des dossiers informatisés). Il retient par exemple l’utilité de check-lists dans des situations spécifiques (interprétation de l’ECG par exemple).
Sloane JF, Donkin C, Newell BR, Singh H, Meyer AND.Managing interruptions to improve diagnostic decision-making : strategies and recommended research agenda. J Gen Intern Med 2023;38(6):1526-1531. Doi : 10.1007/s11606-022-08019-w.
Note :
1- Monteiro SD, Sherbino JD, Ilgen JS, et al. Disrupting diagnostic reasoning: Do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? Acad Med 2015;90(4):511-517.