The Canadian Adverse Events Study: The Incidence Of Adverse Events Among Hospital Patients In Canada G. Ross Baker, Peter G. Norton, Virginia Flintoft, Régis Blais, Adalsteinn Brown, Jafna Cox, Ed Etchells, William A. Ghali, Philip Hébert, Sumit R. Majumdar, Maeve O'Beirne, Luz Palacios-Derflingher, Robert Reid, Sam Sheps, Robyn Tamblyn Research funded by CIHI and CIHR [email protected]May 11, 2006
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The Canadian Adverse Events Study: The Incidence of Adverse Events among hospital patients in Canada
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The Canadian Adverse Events Study: The Incidence Of Adverse Events Among Hospital Patients
In Canada
G. Ross Baker, Peter G. Norton, Virginia Flintoft, Régis Blais, Adalsteinn Brown, Jafna Cox, Ed
Etchells, William A. Ghali, Philip Hébert, Sumit R. Majumdar, Maeve O'Beirne, Luz Palacios-Derflingher,
Nova Scotia: Brenda Brownell, Dr. Tom Casey, Dr. John Fraser, Kelly Goudey, Dr. Ron Gregor, Celeste Latter, and Dr. Allan ShlossbergQuébec : Dr. Edouard Bastien; Dr. Richard Clermont, Evelyne Jean,Cécile Lavoie, Dr. André Rioux. Julie Robindaine, and Daphney St-GermainOntario: Dr. Ed Etchells, Virginia Flintoft, Wilhelmine Jones, Dr. Peter Kopplin, Dr. David MacPherson, and Elaine ThielAlberta: Fatima Chatur, Dr. Leslie Cunning, Dr. Peter Hamilton, Dr. Narmin Kassam and Carolyn NilssonBritish Columbia: Karen Cardiff, Dr. Robert Crossland, Dr. Iain Mackie, Cheryl Marr, Dr. Jacob Meyerhoff, Eva Somogyi and Dr. Robert Wakefield
Example• An adverse event and (likely) preventable
(ie., potentially curable last year, now not)• Caused by an omission….
– If only, the radiologist had called– If only, the resident had seen the XRay– If only, the staffman had read the report– If only, other urologists had read the report– If only the patient had complained…
Quality In Australian Health Care Study Med J Australia Nov 1995
• 14,000 admissions to 28 hospitals in New South Wales and South Australia
• Used HMPS methods, but redefined AE• 17% of admissions had an adverse event• 50% preventable. • 77% lasted < 12 months; • 5% of the patients died• Deaths ‘due to’ AE’s: 1/250 admissions
• Stage 1: using explicit criteria, nurse reviewers flagged patient records that MAY have had an adverse event
• Stage 2: using explicit criteria, physician reviewers determined if an adverse event occurred – and using judgment assessed the degree of preventability
• Nurse reviews based on 18 “triggers”• Triggers included (partial list):
– Unplanned admission before index admission– Unplanned readmission after discharge from index admission– Hospital incurred patient injury– Adverse drug reaction– Unplanned transfer from general care to intensive care– Unplanned return to OR– Development of neurological deficit not present on admission– Unexpected death
Note 1: 388 not eligible for inclusion: Less than 24 hour stay (n=261); Obstetrics (n=56); Transfer in from other hospital (n=48);Cardiac arrest on arrival with subsequent death (n=3); Rehab or Respite care (n=2); Psychiatric (n=2); Unable to determine (n=16).
Virtually certain evidence of preventability (examples)3. Admission because of severe anemia. The
anemia had been documented in previous admission but not investigated fully, which resulted in delayed diagnosis of colorectal carcinoma
5. Clostridium difficile colitis following antibiotic therapy. Patient did not receive sufficient volume expansion, which led to acute renal failure and death
Length of stay• Patients experiencing AEs have longer stays in
hospitals– Teaching hospitals 11 days versus 5 days (medians)– Large 8 days vs 5– Small 6 vs 4 for those with none
• Physician reviewers using professional judgementestimated that the 255 patients with AEs required an additional 1521 days in hospital directly related to their adverse event
Limitations• Retrospective chart review: hindsight bias• Budget constraints: only 20 hospitals in five provinces• Very small or remote hospitals were not studied• Only adult patients in acute care general hospital• Excluded those with a most responsible diagnosis in
obstetrics or psychiatry• Our reliability measurement: only moderate agreement
among physicians in assessing injury, preventability and the contribution of healthcare management to AE
• The additional length of stay attributed to the AE was based on the physician’s professional opinion and interpretation of the patient chart
• 2004 Commonwealth Fund International Health Policy Survey in Australia, Canada, New Zealand, the United Kingdom, and the United States
• Adults• 1400 per country and 3061 in the UK
Schoen C, et. al. Primary care and health system performance: Schoen C, et. al. Primary care and health system performance: adults' experiences in five countries. adults' experiences in five countries. Health Health AffAff (Millwood).(Millwood). 2004 2004 JulJul--Dec;SupplDec;Suppl Web Exclusives:W4Web Exclusives:W4--487487--503.503.