Trusts should use more than one method to detect adverse events
Review of records can identify adverse events that might otherwise
be missed |
Trusts should introduce more than one method of adverse event detection. This is the conclusion of a recent report in Quality and Safety in Health Care
(2007;16:40–4).
Researchers reviewed the numbers and types of adverse incidents
identified by three different methods — routine incident
reporting to a hospital’s confidential system; routine surveillance
of inpatient prescriptions and medicines administration by pharmacists
during a patient’s stay; and clinician review of medical
records 10 days after discharge.
In the study group of 288 patients admitted to a district general
hospital, pharmacist surveillance detected 30 medicines-related
potential adverse events and clinician review detected 14, with
three of these reports overlapping. Pharmacist surveillance mainly
detected failures to prescribe regular or indicated medicines (15/30)
and failures to prescribe correct doses (9/30), while clinician
review mainly detected failures to monitor the effects of medicines
adequately (5/14, with pharmacist surveillance detecting less than
half of these) and polypharmacy leading to side effects in elderly
patients (4/14). No medicine-related events were detected using
incident reporting.
A total of 66 adverse events of any nature (ie, including those
that were not medicines-related) were detected by clinician review
and 11 by incident reporting.
The authors conclude that incident reporting alone is not enough
to gain a comprehensive picture of the areas of risk in clinical
care and that a portfolio of systems should be used in an integrated
and systematic way.
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Hospital
Pharmacist