Monitoring adverse events in hospitals

200 Pages·2017·5.28 MB·English

by  Rebecca Baines

UITNODIGING

Voor het bijwonen van de openbare
verdediging van mijn proefschrift

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MONITORING ADVERSE EVENTS IN HOSPITALS
How safe are hospitals for patients?
Rebecca J. Baines
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ISBN: 978-94-92679-28-4
NUR: 100
Cover design: proefschriftenprinten.nl
Cover illustration: Markovka
Layout and printing: Print Service Ede
© 2018 Rebecca J. Baines. All rights are reserved. No part of this thesis may be reproduced,
distributed or transmitted in any form or by any means without prior written permission of
the author.
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VRIJE UNIVERSITEIT
MONITORING ADVERSE EVENTS
IN HOSPITALS
How safe are hospitals for patients?
ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad Doctor aan
de Vrije Universiteit Amsterdam,
op gezag van de rector magnificus
prof.dr. V. Subramaniam,
in het openbaar te verdedigen
ten overstaan van de promotiecommissie
van de Faculteit der Geneeskunde
op donderdag 8 februari 2018 om 11.45 uur
in de aula van de universiteit,
De Boelelaan 1105
door

Rebecca Johanna Baines
geboren te St. Asaph, Groot-Brittannië
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promotor: prof.dr. C. Wagner
copromotoren: prof.dr. M.C. de Bruijne
dr. M. Langelaan
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Table of conTenTs

cHaPTeR 1 Introduction 7

PART I
Monitoring of adverse events and preventable adverse events 2004-2012
cHaPTeR 2 Changes in adverse event rates in hospitals over time: a longitudinal 23
retrospective patient record review study
cHaPTeR 3 How effective are patient safety initiatives? A retrospective patient 47
record review study of changes to patient safety over time.
cHaPTeR 4 Intra-rater agreement in adverse event studies: stability of assessment of 73
adverse events over time
PART 2
Descriptive studies illustrating patients and processes at risk
cHaPTeR 5 Is researching adverse events in hospital deaths a good way to describe 93
patient safety in hospitals: a retrospective patient record review study
cHaPTeR 6 Medication-related adverse events during hospitalisation: 111
a retrospective record review study in the Netherlands.
cHaPTeR 7 What are the safety risks for patients undergoing treatment by multiple 129
specialties: a retrospective patient record review study
cHaPTeR 8 Association of admission and patient characteristics with quality of 147
discharge letters: posthoc analysis of a retrospective study
cHaPTeR 9 General discussion 161
Summary 175
Samenvatting 183
Dankwoord 191
Publications 195
About the author 197
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1
Introduction

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InTRoducTIon 9
First do no harm
1
This is a fundamental principle that medical students, nurses and other healthcare staff are
taught and work by. Similar words are also a part of the oath of medical students at their
graduation in the Netherlands. However, despite the very best of intentions of healthcare
workers, harm to patients caused by health care, is of all times.
Patient safety has been high on the international agenda for several decades since the
Harvard Medical Practice Study (HMPS) in 1990 and the report ‘To Err is Human’ of the Institute
Of Medicine (IOM) in 1999.[1,2] The HMPS was the first study to estimate how many patients
suffered from health care related harm, through large scaled retrospective patient record
review. The IOM report concluded, based upon a number of studies, that between 44,000 and
98,000 hospitalised patients in the US die each year as a result of medical error and that health
care providers and governments should set up efforts to improve patient safety.[2] After the
HMPS results and the IOM report the world started to realise that hospitals are in potential an
unsafe place to be for patients, despite medical and technological progress over the years.
Many countries, as the Netherlands, have followed the HMPS in assessing health care related
harm, i.e. adverse events, in hospitals and the results have increased the sense of urgency
to take countermeasures to guarantee the safety of patients in hospitals throughout the
world (table 1).[1;3-22] These studies are all cross-sectional studies, estimating (national)
incidences of adverse events and often the preventability at a certain point in time. The
incidence of adverse events varies from 2.9% to 16.6%, of which 22% to 70% are more than
likely to be preventable (table 1). In the Netherlands the incidences are on the low side of
the spectrum, in comparison with other countries. The differences in range may reflect
differences in definitions as well as differences in quality and safety of care.[23]
Initiatives to improve patient safety have followed the publishing of incidences of adverse
events and preventable adverse events. As a result, over the last 10 years, large scaled quality
and safety campaigns have taken place in many countries all over the world. The adverse
event studies have also helped guide prioritising important improvement themes for these
large campaigns. In the Netherlands two large scaled quality and safety improvement
programmes have taken place from 2004 to 2012. The inevitable question arises if patients
are safer now than say 10 or 20 years ago.
On a more detailed level, research is available studying the effects of interventions aimed
at more specific patient safety hazards. National follow-up of large scaled adverse events
studies to provide a good general sense of the burden of preventable harm to patients
caused by health care on the other hand are seldom performed. In the Netherlands we have
monitored the level of patient safety during the years alongside the national quality and
safety programmes through performing three national adverse event studies.

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