Back to Annual Meeting Page		American Public Health Association 133rd Annual Meeting & Exposition December 10-14, 2005 Philadelphia, PA

Abstract #105933

Regis Blais, PhD and Derson Bruno, MD. GRIS, University of Montreal, PO Box 6128, Station Centre-ville, Montreal, QC H3C 3J7, Canada, (514) 343-5907, regis.blais@umontreal.ca

The standard method to assess hospital adverse events is retrospective chart review. However, this method is costly and can only provide delayed information. Alternatively many hospitals routinely collect data through "incident reports" where health care providers take note of adverse outcomes experienced by patients. Yet little is known about the value of these incident reports to detect adverse events. The objectives of this study were: (1) to assess the proportion of adverse events measured through chart reviews that are detected by incident reports and (2) to determine the types of adverse events most and least detected by incident reports. A systematic sample of 2213 charts of adult patients hospitalized in 19 short stay hospitals in the province of Quebec, Canada were systematically reviewed to measure adverse events. The presence of incident reports was also noted in these charts. Adverse events were defined as injuries or complications caused by health care and that lead to disability, death, prolonged hospital stay or readmission. Results showed that incident reports were present in only 15.5% of charts with adverse events, but also in 4.5% of charts without adverse events. The proportion of adverse events detected by incident reports was highest for fracture (50%) and anaesthesia (50%) problems, and lowest for diagnosis error (6%) and other types of events (8%). In their current form, incident reports are not a reliable way to detect hospital adverse events as defined in this study. They may catch some undesirable situations experienced by patients, but to be useful for quality assurance, the information that they collect should be expanded to cover a wider range of adverse events. Given their routine use in hospitals and their relatively low cost, efforts should be made to make better use of incident reports to improve patient care.

Learning Objectives: At the conclusion of the session, the participant (learner) in this session will be able to

• Define what is a hospital incident report
• Assess the value of incident reports in detecting hospital adverse events
• Identify the characteristics of adverse events most detected by incident reports.

Keywords: Quality of Care, Safety

Presenting author's disclosure statement:

I wish to disclose that I have NO financial interests or other relationship with the manufactures of commercial products, suppliers of commercial services or commercial supporters.

Recorded presentation