175804 Safety events during hospitalizations in a cohort of individuals with mental illness: A chart review pilot study

Wednesday, October 29, 2008: 11:15 AM

Jennifer H. Hayes, MEd MPH , Epidemiology and Health Policy and Management, Johns Hopkins University, Catonsville, MD
David Thompson , Johns Hopkins University, Baltimore, MD
Daniel Ford, MD , Johns Hopkins University, Baltimore, MD
Lisa Dixon, MD, MPH , Department of Pyschiatry, University of Maryland, Baltimore, MD
Peter Pronovost , Johns Hopkins University, Baltimore, MD
Donald Steinwachs, PhD, MS , Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
Julia Skapik , Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD
R. Boonyasai , Johns Hopkins University, Baltimore, MD
Gail Daumit, MD MHS , Department of General Internal Medicine, Johns Hopkins University, Baltimore, MD
Background: Safety events are an area of concern in hospitalizations, and may be especially important for persons with severe mental illness (SMI). Adverse events during medical hospitalizations were studied in a population with SMI.

Methods: A multidisciplinary team developed a patient safety instrument targeted for persons with SMI, reviewed hospital charts and recorded adverse events and harms. A sample with two or more hospitalizations during 1994-2004 was chosen from a cohort of 400 Maryland Medicaid recipients with SMI. At least two reviewers abstracted each chart and adjudicated discrepancies. The overall kappa was 0.79, and the kappa for safety events was 0.43.

Results: Seventy four hospitalizations were examined for thirty-two SMI patients. Mean age was 53 years, 81% were female; 69% were African American. The average hospitalization was 7.66 (SD 6.52) days. A total of 540 safety events were found, mean 7.3 (SD 6.6) per hospitalization. 24% of events were associated with physical harm and 31% of events resulted in increased health care utilization. The most common categories of events were general inpatient (e.g, falls, loss of consciousness) (37% of events; 55% of hospitalizations) and medication-related (14% of events; 70% of hospitalizations). Reviewers rated patient mental status as contributing to 18% of events and providers as contributing to 73% of events.


Safety events occurred with an alarming frequency in the population studied. These results indicate that patient quality of care issues need to be addressed in populations of individuals with mental illness.

Learning Objectives:
Describe a chart review pilot study. Define adverse events. Identify adverse events found during hospitalizations and factors that contributed to them.

Keywords: Mental Illness, Mental Health Services

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am actively involved in the data analysis and research.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.