hospital patients' reports of medical errors and undesirable events in their health care

Hospital patients’ reports of medical errors and undesirableevents in their health carejep_1867 1..7

Rachel E. Davis PhD,1 Nick Sevdalis PhD,2 Graham Neale FRCP,3 Rachel Massey MRCS (Eng)4 andCharles A. Vincent PhD5

1Research Associate, 2Senior Lecturer, 3Emeritus Professor, 4Clinical Research Fellow, 5Professor of Patient Safety, Imperial College London,Clinical Safety Research Unit, Department of Bio-Surgery and Surgical Technology, St. Mary’s Hospital, London, UK

Keywords

incident reporting, medical error, patientparticipation, undesirable event

Correspondence

Dr Rachel DavisClinical Safety Research UnitDepartment of Surgery and TechnologySt. Mary’s Hospital10th floor, QEQMSouth Wharf RoadLondon W2 1NYUKE-mail: [email protected]

Conflicts of interest: None.

Accepted for publication: 19 March 2012

doi:10.1111/j.1365-2753.2012.01867.x

AbstractObjective To investigate hospital patients’ reports of undesirable events in their healthcare.Design Cross-sectional mixed methods design.Participants A total of 80 medical and surgical patients (mean age 58, 56 male).Intervention Patients were interviewed post-discharge using a survey to assess patientreports of errors or problems in their care. Patients’ medical records and notes were alsoreviewed.Main outcome measures Frequency of health care process problems, medical complica-tions and interpersonal problems, and patient willingness to report an undesirable event intheir care.Results In total, 258 undesirable events were reported (rate of 3.2 per person), including136 interpersonal problems, 90 medical complications and 32 health care process prob-lems. Patients identified a number of events that were reported in the medical records (30out of 36). In addition, patients reported events that were not recorded in the medicalrecords. Patients were more willing (P < 0.05) to report undesirable events to a researcher(as in the present case) than to a local or national reporting system.Conclusion Patients appear able to report undesirable events that occur in their health caremanagement over and above those that are recorded in their medical records. However,patients appear more willing to report these incidents for the purpose of a study rather thanto an established incident reporting system. Interventions aimed at educating and encour-aging patients about incident reporting systems need to be developed in order to enhancethis important contribution patients could make to improving patient safety.

IntroductionIt recent years, the role that patients could play in the detection andprevention of medical errors has been highlighted [1–3]. Givenpatients are at the centre of the treatment process, there is a highincentive for them to help ensure their care is delivered in thecorrect manner [4]. In addition, as opposed to clinical staff whocome and go (e.g. because of shift changeover), patients observealmost the whole process of care. While patients may not fullyunderstand the technical and clinical issues at stake, they doobserve and experience the skill in which care is delivered, as wellas inconsistencies in care, minor errors and, less often, disasters[4].

At present, knowledge on medical errors and adverse eventsmainly originates from retrospective record review studies andreports of the health care professional [5–10]. While both sourcesof information have their strengths, they also have limitations

[11–13]. Given variable standards in documenting adverse eventsand clinician oversight or fears of litigation, it is recognized thatsuch incidences are often not recorded in medical records [14–19].Systems that rely on doctors voluntary reporting of errors are alsoknown to suffer from widespread under-reporting [4,5,17]. Thereis a distinct gap in the knowledge base from the patients’ perspec-tive. Retrospective accounts from patients could provide informa-tion on vulnerabilities within health care systems, highlightingspecific instances when things did go wrong and why [1–3]. Inaddition, real-time accounts from patients where they ‘speak up’when an error has occurred in their care could help to mitigate anydeleterious effects [20].

For the purpose of this paper, we will focus on the contributionsthat patients could make by providing retrospective accounts. Therole of the patient in detecting and retrospectively reportingadverse events or errors is a novel area of interest, which research-ers are now beginning to investigate [1–3,21,22]. Preliminary

bs_bs_banner

Journal of Evaluation in Clinical Practice ISSN 1365-2753

© 2012 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 1

evidence indicates that patients can provide useful information bydetecting errors that are not recorded in their medical records[21,22] or hospital incident reporting system [3]. However, dataalso suggest that when patients are asked to report ‘unsafe acts’ intheir care, reviewers often classify these events as service qualityincidents rather than adverse events or errors that result in harm[23]. This findings suggest that patients may conceptualizemedical errors more broadly than the traditional medical definitionand preliminary evidence exists to support this view [24].

At present, the majority of extant data on patients’ retrospectivereports of medical errors originates from the United States[1,22,23] or Switzerland [2,3]. There is a paucity of researchwithin the hospital setting in the United Kingdom. In addition,there are very little data to suggest how willing patients would beto provide accounts of errors that occurred in their care; simplyput, we do not know whether patients are happy to take on thisrole.

The present investigation aims to address these gaps in theevidence base. Specifically, we investigated UK patients’ willing-ness and ability to provide information about medical errors orundesirable events they experienced whilst hospitalized.

Methods

Design

A mixed-methods design was employed using a cross-sectionalpatient survey and a review of case records. Ethical approval forthe study was obtained.

Patient eligibility and enrolment

Medical and surgical patients (post-operation) were recruited fromsix wards of an inner city London teaching hospital. Patients wereeligible to participate if they were over 18 years of age, spoke theEnglish language and were able and willing to give informedconsent to participate. Patients also had to have a minimum lengthof 4 days stay in hospital. This cut-off point was decided jointlywith an expert panel of consultant surgeons and doctors of theresearch group, on the basis that patients were less likely to expe-rience many detectable errors or other problems in less than4 days. Patients that worked as health care professionals wereexcluded.

Patient surveys

Our survey was developed by generating a list of questions fromsimilar studies in patient involvement in error reporting [1–3]. Wealso consulted an expert panel of clinicians for their advice on anyitems that should be included/excluded. To ensure comprehension,items in the survey were pre-tested iteratively with 20 hospitalizedpatients. Minor modifications to the survey were made in accor-dance with patient feedback – these related to revising the medicalterminology into more ‘layman’ language.

The final survey tool comprised 31 items. Twenty-seven itemswere categorized as health care process problems (12 items),medical complications (eight items) or interpersonal problems(seven items). Patients had to answer whether any of the eventsoccurred during their care (response format: ‘yes’, ‘no’ or ‘do not

know’). In addition, three items assessed how willing patientswere to report errors to (1) a researcher; (2) a local incidentreporting system (in this case a local hospital system); or (3) anational incident reporting system (here we gave the example ofNational Patient Safety Agency’s National Reporting and Learn-ing Service). Response formats were on a scale of 1–7 (7 being themost willing). Finally, patients were given the opportunity toprovide any open-ended comments (one item) about any of theevents in the survey they reported experiencing or any other prob-lems or errors in their care they wished to discuss (not covered inthe survey).

Medical record reviews

An expert panel of clinicians reviewed the patient surveys andnoted the events mentioned by patients (if any) that should bereported in the patients’ records. Events clinicians stated would‘definitely not be recorded’ in the patients’ medical records wereomitted from further analyses. The remaining events, which allrelated to medical complications or care problems, were rated bythe clinicians as ‘definitively should be recorded’ or ‘maybewould be recorded’ in the patients’ records. The final case recordreview form consisted of 20 items, which specifically assessedthe occurrence of these health care process problems or medicalcomplications.

Procedure

Patients were approached on the hospital wards, explained thenature of this study and asked for their informed consent to par-ticipate. Socio-demographic information (sex, age, ethnicity,employment and education) and information on prior hospitaliza-tion episodes was collected together with the patient’s telephonenumber so the researcher (RD) could telephone them post-discharge to go through the survey. The reason for questioningpatients post-discharge was so data on the whole process of carecould be captured. The patient’s hospital number was recorded sothat medical notes (including discharge summaries, nursing notesand medical records) could be tracked and retrieved for thepurpose of clinical review.

All patients were surveyed over the telephone between5–15 days post-discharge (mean 6.74, SD 1.76). Patients’ medicalnotes were reviewed by two clinicians experienced in case recordreview (GN and RM). A reliability check was performed prior todata collection to ensure inter-rater reliability (kappa = 0.97).

Data coding and analyses

In this study, we refer to all events examined in the patient surveyas ‘undesirable events’ and define these as ‘an unintended or unex-pected incident, which could have, or did lead to harm for thepatient – this could be physical, psychological or financial’. It isimportant to point out here that medical errors would fall withinthe category of undesirable events but that not all undesirableevents could be classified as errors. The focus of the study was keptintentionally broad to capture both true errors or near misses, aswell as other factors that patients perceive as related to care qualitybut are not classified as errors (e.g. poor-quality food, unfriendlystaff).

Patient reports of medical errors R.E. Davis et al.

© 2012 Blackwell Publishing Ltd2

Chi-squared tests were performed to investigate significant dif-ferences between patient characteristics and responses to items inthe survey. Analyses of variance were performed to explore sig-nificant differences between patient characteristics and patients’willingness to report an error. Patients’ open-ended comments onproblems that occurred in their care were submitted to thematiccontent analysis: patients’ responses were recorded verbatim andthen coded into themes by two researchers. In order to comparepatients’ self-reports with the record review, the frequency orevents reported by both methods were tabulated.

Results

Participants

Eighty patients agreed to participate (82% response rate). Patientsdeclined because of lack of interest in the study (n = 8); timeconstraints – having to leave for medical tests before reading theinformation sheet (n = 2); and patients not being well enough toread the information sheet (n = 8). Table 1 displays descriptiveinformation on participants.

Patient surveys

Table 2 presents descriptive information on patients’ responses toeach of the individual items in the survey relating to health careprocess problems, medical complications or interpersonal prob-lems (27 items in total). Affirmative responses indicate less-favourable assessments of care. In total, 258 undesirable events

were reported (rate of 3.2 per person). Patients reported 32 healthcare process problems (12% event rate), 90 medical complications(35% event rate) and 136 interpersonal problems (53% event rate).

Associations between responses and patients’ characteristicswere explored. Surgical patients were more likely than medicalpatients to report developing an inflammation of the vein(c2 = 6.40, d.f.2, P < 0.05) and that their intravenous fluids had notbeen changed when they should have been (c2 = 4.88, d.f.2,P < 0.05). No other significant differences were found.

Patients’ willingness to reportundesirable events

There were significant differences between patients’ willingness toreport undesirable events using the 3 different methods we pre-sented to them (F(2, 234) = 163.5, P < 0.001). Post hoc comparisonswith Bonferoni correction revealed that patients were more willingto report events for the purpose of a study (mean = 6.19, SD 0.73),than report to a local reporting system (mean = 5.00, SD 0.71;P < 0.001) or to a national reporting system (mean = 3.83, SD0.98; P < 0.001). Between the two reporting systems, patientswere more willing to use the local one (P < 0.001).

Additional problems patients reported intheir care

From the total sample (n = 80), 42 patients provided open-endedcomments concerning problems in their care not covered in thesurvey. In total, 58 problems were reported (rate of 1.4 per person).These were categorized into four different themes – environment,service received, health care professionals and care procedures.Table 3 summarizes these themes and provides examples ofpatients’ verbatim quotes for each.

Comparisons between patient reports andmedical records

Table 4 presents the level of agreement between the number ofmedical complications and health care process problems reportedby patients and recorded in patients’ records. The results show thatpatients were able to detect many of the errors recorded in themedical records (30 out of 36). Patients also identified a number ofevents not included in the records that reviewers felt ‘definitely’should have been included (n = 27).

DiscussionTo the best of our knowledge, this study is the first of its kind in theUnited Kingdom to empirically investigate patients’ willingnessand ability to report undesirable events in health care and comparethe reports with information recorded in patients’ medical records.In total, patients reported 258 undesirable events in their healthcare, the majority of which were interpersonal problems.

The most commonly reported events related to lack of explana-tions on how the hospital ward operates (e.g. what time meals are)and what to expect in terms of their treatment. While these eventsare not errors per se, they could still lead to negative effects (eitherpsychological or physical) on the patient. For most patients, hos-pitalization is an unfamiliar experience and a situation where they

Table 1 Patient characteristics

Socio-demographic variables No. of subjects (%)

SexMale 56 (70)Female 24 (30)

EducationNo qualifications 21 (26.25)GSCEs 21 (26.25)A levels 9 (11.25)Undergraduate degree 20 (25)Postgraduate degree 4 (5)Vocational training 5 (6.25)

RaceCaucasian 64 (80)Non-Caucasian 16 (20)

EmploymentEmployed 33 (41)Unemployed 8 (10)Retired 33 (41)Student 3 (4)Registered disabled 3 (4)

SpecialityMedical 45 (56.2)Surgical 35 (43.8)

Age 19–88 (mean 58, SD 16.6)Length of stay (in days) 4–12 (mean 6.19, SD 1.95)Previous number of times in hospital 0–15 (mean 3.77, SD 3.53)

R.E. Davis et al. Patient reports of medical errors

© 2012 Blackwell Publishing Ltd 3

Table 2 Descriptive from the patients’ surveys

Yes (%) No (%) Do not know (%)

Medical complications

You develop a sore arm or inflammation because of a drip (intravenous line)? 11 (13.75) 68 (85) 1 (1.25)You caught an infection in the hospital? 6 (7.5) 72 (90) 2 (2.5)You experienced a reaction to a drug? 5 (6.25) 74 (92.5) 1 (1.25)You bled a lot after an operation or after a tube was inserted into you (catheterization)? 5 (6.25) 74 (92.5) 1 (1.25)You needed to be transferred to intensive care because of a complication that occurred in hospital? 2 (2.5) 78 (97.5)You developed a pressure ulcer (skin wound) in hospital? 1 (1.25) 79 (98.75)You had to be re-operated on urgently within 3 days of an initial operation? 1 (1.25) 79 (98.75)You were injured as result of fall in hospital? 1 (1.25) 77 (96.25) 2 (2.5)

Health care process problems

Your medical records were unavailable when needed? 17 (21.25) 33 (41.25) 30 (37.5)You did not receive enough painkillers? 29 (36) 44 (55) 7 (9)Doctors made a wrong diagnosis? 3 (3.75) 75 (93.75) 2 (2.5)You were given food/drink you were not allowed on your diet? (e.g. if you were NBM) 3 (3.75) 73 (91.25) 4 (5)Your fluids in your drip were not changed when they should have been 10 (12.5) 57 (71.25) 13 (16.25)A test was not done when it should have been? 13 (16.25) 59 (73.25) 8 (10)A test was repeated needlessly, by mistake? 1 (1.25) 75 (93.75) 4 (5)You were given a drug that was not intended for you? 2 (2.5) 78 (97.5)You were confused with another patient during a test or a treatment? 2 (2.5) 78 (97.5)A test was cancelled by mistake? 1 (1.25) 75 (93.75)You were prescribed a medicine you were allergic to? 2 (2.5) 76 (95) 2 (2.5)An error occurred in a test result? 7 (8.75) 73 (91.25)

Interpersonal problems

The side effects of your medication were not explained to you? 28 (35) 49 (61.25) 3 (3.75)Health care staff did not introduce themselves and explain who they were? 7 (8.75) 70 (87.5) 3 (3.75)You were not explained how the ward works? (e.g. where the toilets are, what time meals are?) 42 (52.5) 36 (45) 2 (2.5)You were not explained about what to expect from your treatment while in hospital? 31 (38.75) 48 (60) 1 (1.25)You were not given enough information about your care after discharge from hospital? 18 (22.5) 62 (77.5)You were not treated with dignity and respect by the doctors and nurses? 4 (5) 76 (95)You did not feel that you could ask questions to doctors and nurses if you wanted to? 6 (7.5) 74 (92.5)

Table 3 Patients’ open-ended reports of additional problems in their care

ThemeFrequencymentioned Verbatim quotes

1. Environmentalrelated

14 ‘Bays very busy. . . too busy’‘The ward did not look very tidy. . . I though it needed cleaning’‘There should not be mixed bay wards it does not respect dignity of one’‘Food was awful. . . also I am a vegetarian and they gave me a meal with meat in’

2. Service-related 5 ‘I was sick in my bed and had to wait for ages for the sheets to get changed. . . I don’t think its acceptable’

3. Health careprofessionalrelated

29 ‘Staff were too busy to ask questions to’‘Staff were not sympathetic to my needs’‘I was given too many painkillers and when I told the doctor he did nothing’‘Doctors did not answer by questions, they were very evasive’‘Staff were very patronising – they spoke to me like I was 5 years old’‘I did not receive adequate information from HCPs to know what to expect in terms of my treatment’‘Staff assumed I knew what was happening and did not provide me with any useful information’‘The nurse was wearing a dirty plaster on her hand’

4. Procedurerelated

10 ‘Its annoying when you go into hospital. . . your expect things to be done there and then and then you endup waiting round for ages’

‘I was NBM all day and then my operation was postponed until the next day’‘I had to wait 6 hours for my medicines – this seems ridiculous to me’



have to relinquish a lot of control. If patients feel particularlyuninformed on what to expect during their hospital stay, this canheighten patient anxiety. In addition, if patients have not beengiven information regarding their treatment or explained informa-tion in a way they understand, this can result in patient non-adherence to medical advice. This, in turn, could catalyze thelikelihood of a treatment complications or re-admission intohospital.

The most frequently cited problem with the care process wasinadequate analgesia. A possible explanation is that staff maysimply be too busy to pay enough attention to individual patientsanalgesia needs. However, what may be more likely is given painis a subjective experience it is difficult to judge its level in anotherperson. Indeed, there is evidence that this is the case for health carestaff – research has shown when patients’ reports are compared tonurses’ reports, nurses often underestimate the level of pain thatpatients are experiencing [25]. This is one area in particular, there-fore, where patients should be encouraged to speak up.

A large number of patients also stated that their medical recordswere unavailable when needed. Patients, providing they have therequisite knowledge could help to alleviate problems associatedwith inaccessible medical records by providing important

information required by health care staff; for example, currentsymptoms, medical history and tests or procedures they areawaiting.

In relation to medical complications, the most common eventscited were developing a sore arm because of an intravenous dripand catching an infection in hospital. If patients are able to identifyand report these events to health care staff, they could mitigate(any) negative effects. It remains to be seen, however, how com-fortable patients feel to raise such issues. Some existing evidencesuggests that they may not be willing to engage in such behaviours[26–28].

Patients also provided a number of additional comments relat-ing to general problems in care – for example, the hospital wardbeing too busy, poor-quality food or feeling unable to ask healthcare staff questions. Many patients complained that staff wereevasive or patronizing. This has important implications for patientsafety given communication problems are a major contributoryfactor to errors [29]. If we are trying to encourage patients to speakup and alert health care professionals to errors, this can only besuccessfully achieved if patients feel comfortable doing this.

In terms of the level of agreement between patients’ reports andthe data extracted from the medical records, overall results were

Table 4 Level of agreement between patients’ reports and medical notes

Survey item

Total numberof eventsreported

Numberreported bypatients

Numberrecordedin notes

Number reported bypatient that werefound in notes

Medical complications

You caught an infection in the hospital? 7 6 5 4/5You experienced a reaction to a drug? 5 5 1 1/1You bled a lot after an operation or after a tube was inserted

into you (catheterization)?5 5 0 0

You needed to be transferred to intensive care because ofa complication that occurred in hospital?

2 2 1 1/1

You developed a pressure ulcer (skin wound) in hospital? 3 1 2 0/2You had to be re-operated on urgently within 3 days of an initial operation? 1 1 1 1/1You were injured as result of fall in hospital? 1 1 1 1/1You develop a sore arm or inflammation because of a drip (intravenous line)? 12 11 6 5/6

Health care process problems

Doctors made a wrong diagnosis? 3 3 1 1/1You were given a drug that was not intended for you? 2 2 1 1/1You were confused with another patient during a test or a treatment

you were given?2 2 0 0

You were prescribed a medicine you were allergic to? 2 2 0 0An error occurred in a test result? 7 7 0 0Your medical records were unavailable when needed? 17 17 6 6/6You did not receive enough painkillers? 31 29 7 5/7You were given food/drink you were not allowed on your diet?

(e.g. if you were NBM)3 3 0 0

Your fluids in your drip were not changed when they should have been? 10 10 1 1/1A test was not done when it should have been? 13 13 2 2/2A test was repeated needlessly, by mistake? 1 1 1 1/1A test was cancelled by mistake? 1 1 0 0Total of events that definitely should have been recorded in records 40 37 13 10/13

Total of events that maybe should have been recorded in records 88 85 23 20/23

Overall total 128 122 36 30/36

Note: Type in normal are those events that ‘definitely should have been included in the medical records’ (n = 25). Type in italic were those events that‘maybe should have been included in the records’ (n = 65).



very promising. A high level of agreement was obtained betweenthe two sources and only six undesirable events were found in themedical records that were not reported by patients. Perhaps moreimportantly, however, patients also reported a number of eventsthat were not recorded in the medical records. It should be notedthat some of these events were deemed by clinicians as only‘maybe being included’ in the records but not ‘definitely beingincluded’ (e.g. medical records not available when needed), whichcould account for some variation in findings. Despite this however,these data indicate that patients can provide information on unde-sirable events in their health care over and above information thatcan be retrieved using more traditional methods of investigation.

Our data suggest that patients vary in their preferences forreporting errors. In this study, patients were more willing to reportevents to a person over the phone (as part of the study) than toreport to a local or national reporting system. The reason for this isunclear although it is likely that lack of perceived benefit couldaccount in part for this. Greater efforts therefore need to be madeto educate patients about the valuable contributions they can maketo aid health care organizations understandings of the aetiology ofmedical errors.

There is still a pressing need for future work in this area. Giventhis is the first study of its kind in the United Kingdom, research isrequired to investigate to what extent findings can be replicatedand also generalized to other patients cohorts. In addition, whilethe present research has shown that patients are able to identifyerrors or problems in their care, we can only learn from patients ifthey are willing to report this information. With this in mind, weneed to learn what the best strategies may be to successfullyencourage patient involvement in this area.

The main limitation of this research is that the study was onlyconducted on patients from one inner city London teaching hos-pital. The study needs to be repeated across other patient speciali-ties and in different hospitals (teaching hospitals and districtgenerals) in order to ascertain the generalizability of the findings.In addition, our sample was not randomly recruited so could havebeen subject to selection bias. Only patients that were able toparticipate and wanted to do so took part in the study; this leavesthe views of a large number of patient populations (e.g. those thatwere too ill or unwilling to participate) unaccounted for. Finally,the validity of patients’ reports of events that did not occur in themedical records need to be verified – this is a topic we intend toinvestigate in future research. Despite these limitations, however,we feel that this study provides important evidence based insightsin an otherwise heavily under-researched area.

ConclusionWhile there is still much to be learnt about the patients’ role inincident reporting, this study shows that patients are able to detecterrors in there care that are recorded in their medical records. Inaddition, patients appear able to report additional events that mayotherwise go undetected. In addition to reporting errors, patientscan provide useful information about problems (i.e. not errors butservice quality problems) that could be used to improve the deliv-ery of health care services. Effective interventions to encouragepatient involvement need to be formulated and evaluated in orderto strengthen the patients’ role in this very important area.

AcknowledgementsThe Clinical Safety Research Unit is affiliated with the Centre forPatient Safety and Service Quality at Imperial College HealthcareNHS Trust, which is funded by the National Institute of HealthResearch.

FundingThis was work was funded by the UK Health Foundation.

References1. Weingart, S. N., Pagovich, O., Sands, D. Z., Li, J. M., Aronson, M. D.,

Davis, R. B., Bates, D.W. & Phillips, R. S. (2005) What can hospitalisedpatients tell us about adverse events? Learning from patient-reportedincidents. Journal of General Internal Medicine, 20, 830–836.

2. Schwappach, D. (2008) ‘Against the silence’: development and firstresults of a patient survey to assess experiences of safety-relatedevents in hospital. BMC Health Services Research, 8, 59–66.

3. Agoritsas, T., Bovier, P. & Perneger, T. (2005) Patient reports ofundesirable events during hospitalisation. Journal of General InternalMedicine, 20, 922–928.

4. Vincent, C. (2006) Patient Safety. Amsterdam: Elsevier.5. Brennan, T. A., Leape, L. L., Laird, N. M., Hebert, L., Localio, A. R.,

Lawthers, A. G., Newhouse, J. P., Weiler, P. C. & Hiatt, H. H. (1991)Incidence of adverse events and negligence in hospitalised patients– Results of the Harvard Medical Practice Study 1. The New EnglandJournal of Medicine, 324, 370–376.

6. Vincent, C., Neale, G. & Woloshynowych, M. (2001) Adverse eventsin British hospitals: preliminary retrospective record review. BMJ(Clinical Research Ed.), 322, 517–519.

7. Leape, L. L., Brennan, T. A., Laird, N., Lawthers, A. G., Localio,A. R., Barnes, B. A., Hebert, L., Newhouse, J. P., Weiler, P. C. & Hiatt,H. (1991) The nature of adverse events in hospitalised patients. Resultsof the Harvard Medical Practice study II. The New England Journal ofMedicine, 324, 377–384.

8. Thomas, E. J., Studdert, D. M., Burstin, H. R., Orav, E. J., Zeena, T. B.S., Williams, E. J., Howard, K. M., Weiler, P. C. & Brennan, T. A.(2000) Incidence and types of adverse events and negligent care inUtah and Colorado. Medical Care, 38, 261–271.

9. Witman, M. D. & Kendall, P. A. (2001) A prospective, physicianself-reported adverse incident audit on a general medical unit. Journalof Quality in Clinical Practice, 21, 61–65.

10. Welsh, C. H., Pedot, R. & Anderson, R. J. (1996) Use of morningreport to enhance adverse event detection. Journal of General InternalMedicine, 11, 454–460.

11. Thomas, E. J. & Petersen, L. A. (2003) Measuring errors and adverseevents in health care. Journal of General Internal Medicine, 18,61–67.

12. Murff, H. J., Patel, V. L., Hripcsak, G. & Bates, D. W. (2003) Detect-ing adverse events for patient safety research: a review of currentmethodologies. Journal of Biomedical Informatics, 36, 131–143.

13. Michel, P., Quenon, J. L., de Sarasqueta, A. M. & Scemama, O. (2004)Comparison of three methods for estimating rates of adverse eventsand rates of preventable adverse events in acute care hospitals. BMJ(Clinical Research Ed.), 328, 199–202.

14. Bates, D. W. (2001) A 40-year-old woman who noticed a medicationerror. JAMA, 285, 3134–3140.

15. Pizzi, L. T., Glodfarb, N. I. & Nash, D. B. (2001) Other practicesrelated to patient participation. In Making Health Care Safer: A Criti-cal Analysis of Patient Safety Practices. Evidence Report/TechnologyAssessment (eds K. G. Shojania, B. W. Duncan, K. M. McDonald &



R. M. Wachter), pp. 575–578. No 43, Rockville, MD: Agency forHealth Care Research and Quality.

16. Weingart, S. N., Ship, A. N. & Aronson, M. D. (2000) Confidentialclinician-reported surveillance of adverse events among medical inpa-tients. Journal of General Internal Medicine, 15, 7: 470–477.

17. Weingart, S. N., Callanan, L. D., Ship, A. N. & Aronson, M. D. (2001)A physician-based voluntary reporting system for adverse events andmedical errors. Journal of General Internal Medicine, 12 (16), 809–814.

18. O’Neil, A. C., Petersen, L. A., Cook, E. F., Bates, D. W., Lee, T. H. &Brennan, T. A. (1993) Physician reporting compared with medical-record review to identify adverse medical events. Annals of InternalMedicine, 119 (5), 370–376.

19. Runciman, W. B., Sellen, A., Webb, R. K., Williamson, J. A., Currie,M., Morgan, C. & Russell, W. J. (1993) The Australian incidentmonitoring study. Errors, incidents and accidents in anaesthetic prac-tice. Anaesthesia and Intensive Care, 21, 506–519.

20. Unruh, K. T. & Pratt, W. (2007) Patients as actors: the patient’s role indetecting, preventing, and recovering from medical errors. Interna-tional Journal of Medical Informatics, 76 (Suppl 1), S236–S244.

21. Friedman, S., Provan, D., Moore, S. & Hanneman, K. (2008) Errors,near misses and adverse events in the emergency department: what canpatients tell us? Canadian Journal of Emergency Medicine, 10, 421–427.

22. Weissman, J. S., Schneider, E. C., Weingart, S. N., Epstein, A. M.,David-Kasdan, J., Feibelmann, S., Annas, C. L., Ridley, N., Kirle, L.& Gatsonis, C. (2008) Comparing patient-reported hospital adverse

events with medical record review: do patients know something thathospitals do not? Annals of Internal Medicine, 149, 100–108.

23. Weingart, S., Price, J., Duncombe, D., Connor, M., Sommer, K.,Conley, K., Bierer, B. E. & Ponte, P. R. (2007) Patient-reported safetyand quality of care in outpatient oncology. Journal on Quality andPatient Safety, 33, 83–94.

24. Burroughs, T., Waterman, A., Gallagher, T., Waterman, B., Jeffe, D.,Dunagan, W., Garbutt, J., Cohen, M. M., Cira, J. & Fraser, V. J. (2007)Patients’ concerns about medical errors during hospitalisation. JointCommission Journal on Quality and Patient Safety, 33, 5–14.

25. Idvall, E., Hamrin, E., Sjostrom, B. & Unosson, M. (2002) Patient andnurse assessment of quality of care in postoperative pain management.Quality & Safety in Health Care, 11, 327–334.

26. Hibbard, J., Peters, E., Slovic, P. & Tusler, M. (2005) Can patients bepart of the solution? Views on their role in preventing medical errors.Medical Care Research and Review, 62, 601–616.

27. Waterman, A. D., Gallagher, T. H., Garbutt, J., Waterman, B., Fraser,V. J. & Burroughs, T. E. (2006) Brief report: hospitalized patients’attitudes about and participation in error prevention. Journal ofGeneral Internal Medicine, 21, 367–370.

28. Marella, W., Finley, E., Thomas, A. & Clarke, J. (2007) Health careconsumers’ inclination to engage in selected patient safety practices: asurvey of adults in Pennsylvania. Journal of Patient Safety, 3, 184–189.

29. Sutcliffe, K. M., Lewton, E. & Rosenthal, M. M. (2004) Communica-tion failures: an insidious contributor to medical mishaps. AcademicMedicine, 79 (2), 186–194.



hospital patients' reports of medical errors and undesirable events in their health care

Documents