Diagnostic adverse events produced more severe consequences compared
with other adverse events and were considered to be preventable in most
instances, new study data indicated.
The study featured a systematic three-stage retrospective review that
included records (n=7,926) of discharged and deceased patients admitted to 21
Dutch acute care hospitals in 2004. Using protocol developed by the Harvard
Medical Practice Study, the physicians reviewed randomly selected hospital
records and selected all adverse events with diagnostic error as the main
category for analysis and compared them with other adverse event types.
Diagnostic adverse events occurred in 0.4% (95% CI, 0.21%-0.59%) of
hospital admissions and represented 6.4% (95% CI, 4.3%-8.5%) of all adverse
events. Of the diagnostic adverse events, researchers determined 83.3% were
preventable. Human failure was identified as the main cause (96.3%), although
factors relating to organization (25%) and the patients (30%) contributed. In
addition, the consequences of diagnostic adverse events had a higher mortality
rate than for other adverse events (29.1% vs. 7.4%).
[Diagnostic adverse events] are an important [adverse event] type
because they are considered to be highly preventable and their consequences are
severe, the researchers wrote. The causes of human and
organizational categories suggest a chain of events that lead to [diagnostic
adverse events], the main causes being knowledge-based mistakes combined with
verification and information transfer problems. Prevention strategies should
focus on better
training of physicians in a context-specific manner and on
organization of knowledge and information transfer.
Zwaan L. Arch Intern Med. 2010;170:1015-1021.
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