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Reporting of Sentinel Events in Swedish Hospitals: A Comparison of Severe Adverse Events Reported by Patients and Providers
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Health and Developmental Care, Patient Safety.
Linköping University, Department of Medical and Health Sciences, Thoracic Surgery. Linköping University, Faculty of Health Sciences.
Östergötlands Läns Landsting, Center for Health and Developmental Care, Patient Safety.
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Health and Developmental Care, Patient Safety.
2011 (English)In: Joint Commission Journal on Quality and Patient Safety, ISSN 1553-7250, E-ISSN 1938-131X, Vol. 37, no 11, 495-501 p.Article in journal (Refereed) Published
Abstract [en]

Background: Mandatory and voluntary reporting of adverse events is common in health care organizations but a more accurate understanding of the extent of patient injury may be obtained if additional sources are used. Patients in Sweden may file a claim for economic compensation from the national insurance system if they believe they have sustained an injury. The extent and pattern of reporting of serious adverse events in a mandatory national reporting system was compared with the reporting of adverse events on the basis of patient claims.

Methods: Regional sentinel event reports were compared with malpractice claims data between 1996 and 2003. A sample consisting of 113 patients with deaths or serious injuries was selected from the malpractice claims data source. The medical records of these patients were reviewed by three chief medical officers.

Results: Of the deaths or injuries associated with the 113 patients—25 deaths, 37 with more than 30% disability, and 51 with 16%-30% disability—23 (20%) had been reported by chief medical officers to the National Board of Health and Welfare as sentinel events. Most adverse events were found in orthopedic surgery, and orthopedic injuries had more serious consequences. None of the patient injuries caused by infections were reported as sentinel events. Individual errors were more frequent in cases reported as sentinel events.

Conclusions: Adverse events causing severe harm are underreported to a great extent in Sweden despite the existence of a mandatory reporting system; physicians often consider them to be complications. Health care organizations should consider using a portfolio of tools—including incident reporting, medical record review, and analysis of patient claims—to gain a comprehensive picture of adverse events.

Place, publisher, year, edition, pages
2011. Vol. 37, no 11, 495-501 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-72589OAI: oai:DiVA.org:liu-72589DiVA: diva2:460184
Available from: 2011-11-29 Created: 2011-11-29 Last updated: 2017-12-08Bibliographically approved
In thesis
1. Measures of Patient Safety: Studies of Swedish Reporting Systems and Evaluation of an Intervention Aimed at Improved Patient Safety Culture
Open this publication in new window or tab >>Measures of Patient Safety: Studies of Swedish Reporting Systems and Evaluation of an Intervention Aimed at Improved Patient Safety Culture
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Unsafe health care delivery results in millions of patients suffering from injuries or death worldwide. A Swedish study estimated the prevalence of preventable adverse events as high as 8.6% in hospital care, which demonstrates that patient safety is no less a problem in Sweden than elsewhere. Reporting of adverse events has become an integral part of patient safety work. The aim of reporting is to identify patient safety problems and provide background data and information for efforts to improve patient safety. However, adverse events in health care can be captured and measured using different methods and stored in disparate systems that are not fully integrated. This makes it difficult to obtain a complete coherent picture of the frequency and nature of various types of adverse events. Another difficulty is to distinguish between adverse events and accepted complications of medical care.

The overall aim of this thesis is to generate knowledge for improved understanding of how patient safety can be measured in terms of reporting adverse events and improved by targeting patient safety culture with an intervention implemented in a Swedish county council. Three research questions have been derived from the aim: (1) To what extent can analysis of patient claims contribute to an understanding of the magnitude of the patient safety problem? (2) To what extent do data captured from different reporting systems in Sweden differ? (3) To what extent can a structured intervention that fosters learning on patient safety issues and encourages leadership commitment improve the patient safety culture in a Swedish county council from a five-year perspective?

The research is based on studies of three national reporting systems: Lex Maria to the National Board of Health and Welfare; patient claims to the County Councils´ Mutual Insurance Company; and medical data reported to the National Swedish Spine Register (Swespine). Data have also been assembled as part of an evaluation within the Patient Safety Dialogue intervention.

This thesis indicates that different Swedish reporting systems provide disparate views and have many discrepancies regarding data quality and coverage of adverse events. Patient claims seem to be an important source of information that can complement information from incident reporting systems and quality registries in health care to provide an understanding of the magnitude of the patient safety problem.

The research also shows that a structured intervention that fosters learning on patient safety issues and encourages leadership commitment can improve the culture of patient safety. However, a longer period of time and focused efforts might be required to achieve improvements across all departments within a Swedish county council.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. 85 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1267
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-72594 (URN)978-91-7393-043-7 (ISBN)
Public defence
2012-01-13, Berzeliussalen, Universitetssjukhuset, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2011-11-29 Created: 2011-11-29 Last updated: 2011-12-16Bibliographically approved

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Öhrn, AnnicaElfström, JohanRutberg, Hans

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