Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital.

Ali Baba-Akbari Sari; Trevor Sheldon; Alison Cracknell; Alastair Turnbull; Yvonne Dobson; Celia Grant; William Gray; Aileen Richardson

Study

Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital.

December 12, 2007

Sari AB-A, Sheldon T, Cracknell A, et al. Qual Saf Health Care. 2007;16(6):434-9.

View more articles from the same authors.

This retrospective study screened hospital admissions for specific triggers to identify adverse events. Approximately 1 in 11 admissions had an adverse event, and 15% of these led to significant disability or death.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.

January 3, 2007

Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review.

March 26, 2008

The role of emotion in patient safety: are we brave enough to scratch beneath the surface?

January 27, 2016

Twelve tips for implementing a patient safety curriculum in an undergraduate programme in medicine.

August 3, 2011

Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review.

June 2, 2010

Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the Huddle Up for Safer Healthcare (HUSH) project.

October 20, 2021

Experience of wrong site surgery and surgical marking practices among clinicians in the UK.

November 15, 2006

Changing experience of adverse medical events in the National Health Service: comparison of two population surveys in 2001 and 2013.

February 14, 2018

Safer prescribing—a trial of education, informatics, and financial incentives.

March 30, 2016

ICU attending handoff practices: results from a national survey of academic intensivists.

December 9, 2015

Strategies for flipping the script on opioid overprescribing.

November 23, 2016

A systems approach to identify factors influencing adverse drug events in nursing homes.

June 27, 2018

Airway carts: a systems-based approach to airway safety.

November 1, 2006

Evaluating service delivery interventions to enhance patient safety.

January 14, 2009

A systematic review of patient tracking systems for use in the pediatric emergency department.

June 6, 2012

On the relationship between safety climate and occupational burnout in healthcare organizations.

October 26, 2016

Review of computerized physician handoff tools for improving the quality of patient care.

December 12, 2012

Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events.

May 16, 2007

Hospital autopsy: endangered or extinct?

July 8, 2015

Persistent noncompliance with the work-hour regulation.

March 2, 2011

Preventing patient positioning injuries in the nonoperating room setting.

August 24, 2022

Injury to research volunteers—the clinical-research nightmare.

May 17, 2006

An analysis of electronic health record–related patient safety incidents.

March 30, 2016

Quantitative analysis of adverse events in neurosurgery.

September 2, 2009

Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial.

June 1, 2016

Register-based research of adverse events revealing incomplete records threatening patient safety.

August 19, 2020

Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.

December 14, 2016

Understanding and responding when things go wrong: key principles for primary care educators.

September 28, 2016

Heatwaves, hospitals and health system resilience in England: a qualitative assessment of frontline perspectives from the hot summer of 2019.

March 22, 2023

Implementing a safe and reliable process for medication administration.

June 6, 2012

New perspectives on error in critical care.

September 17, 2008

Misinformation in the medical literature: what role do error and fraud play?

August 31, 2011

Retractions in the medical literature: how many patients are put at risk by flawed research?

July 6, 2011

Patient misidentification in the neonatal intensive care unit: quantification of risk.

January 18, 2006

From blaming to learning: re-framing organisational learning from adverse incidents.

October 26, 2011

Random safety auditing, root cause analysis, failure mode and effects analysis.

May 19, 2010

Perinatal clinical decision support system: a documentation tool for patient safety.

October 10, 2007

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

February 15, 2023

Helping patients simplify and safely use complex prescription regimens.

March 16, 2011

Patients' and families' perspectives of patient safety at the end of life: a video-reflexive ethnography study.

March 30, 2016

Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial.

June 17, 2009

Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study.

February 15, 2023

Team working in intensive care: current evidence and future endeavors.

September 15, 2010

A patient-centered prescription drug label to promote appropriate medication use and adherence.

January 18, 2017

Between demarcation and discretion: the medical-administrative boundary as a locus of safety in high-volume organisational routines.

August 1, 2018

Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care.

December 13, 2017

Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.

July 19, 2023

Application of the WHO surgical safety checklist outside the operating theatre: medicine can learn from surgery.

November 26, 2014

Implementing an obstetric emergency team response system: overcoming barriers and sustaining response dose.

November 4, 2015

Human factors and error prevention in emergency medicine.

June 15, 2011

Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls.

February 17, 2016

Clinical profile of hospitalized children provided with urgent assistance from a medical emergency team.

June 18, 2008

Crisis resource management in emergency medicine.

March 7, 2012

Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.

January 22, 2014

Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs.

October 25, 2006

The spectrum of medical errors: when patients sue.

September 12, 2012

Using learning communities to support adoption of health care innovations.

July 25, 2018

Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge.

March 28, 2018

Systematic root cause analysis of adverse drug events in a tertiary referral hospital.

March 27, 2005

Health care-associated infections among critically ill children in the US, 2007-2012.

September 24, 2014

Evaluation of the implementation of the alert issued by the UK National Patient Safety Agency on the storage and handling of potassium chloride concentrate solution.

June 29, 2005

Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds.

March 21, 2007

Patient safety and interprofessional education: a report of key issues from two interprofessional workshops.

May 3, 2017

Lost in translation? Addressing barriers in the application of industrial process improvement methodologies to health care.

October 29, 2014

Antiretroviral medication errors in a national medication error database.

January 11, 2006

Finding the patient in patient safety.

February 13, 2013

Towards a model of surgeons' leadership in the operating room.

March 9, 2011

Safer by design.

February 13, 2008

The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.

March 16, 2011

Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.

October 23, 2019

It's not all about me: motivating hand hygiene among health care professionals by focusing on patients.

February 15, 2012

Using simulation to improve patient safety: dawn of a new era.

March 18, 2015

Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit.

July 4, 2007

What are we doing when we double check?

April 1, 2020

Patient safety threats in information management using health information technology in ambulatory cancer care: an exploratory, prospective study.

June 10, 2020

Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences.

September 7, 2016

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.

June 29, 2016

Oncology nurses' beliefs and attitudes towards the double-check of chemotherapy medications: a cross-sectional survey study.

March 21, 2018

Motivational antecedents of incident reporting: evidence from a survey of nurses and physicians.

November 27, 2013

Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons.

March 2, 2022

Registered nurses' judgments of the classification and risk level of patient care errors.

October 19, 2011

Does responsibility affect the public's valuation of health care interventions? A relative valuation approach to health care safety.

July 1, 2012

Reporting of health information technology system-related patient safety incidents: the effects of organizational justice.

October 6, 2021

Level IV evidence—adverse anecdote and clinical practice.

July 27, 2011

Quality gaps identified through mortality review.

February 1, 2017

Clinical information transfer and medication reconciliation in patients transferred from the pediatric intensive care unit.

December 12, 2007

Promoting patient safety using an early warning scoring system.

August 27, 2008

Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review.

October 10, 2018

A hybrid methodology for modeling risk of adverse events in complex health-care settings.

March 15, 2017

Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine.

April 5, 2023

Incident reporting behaviours following the Francis report: a cross-sectional survey.

February 21, 2018

Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspective: progress and challenges.

September 12, 2012

Dynamics of dignity and safety: a discussion.

January 24, 2018

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.

June 14, 2017

The lost sponge: patient safety in the operating room.

October 17, 2012

Narrativizing errors of care: critical incident reporting in clinical practice.

July 20, 2005

Morning handover of on-call issues: opportunities for improvement.

August 6, 2014

Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.

November 13, 2013

Effect of electronic health records in ambulatory care: retrospective, serial, cross sectional study.

April 15, 2005

Identifying risks areas related to medication administrations - text mining analysis using free-text descriptions of incident reports.

February 12, 2020

Related Resources

Healthcare Safety Investigations Conference 2022.

August 3, 2022

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales.

November 11, 2020

COVID-19: patient safety and quality improvement skills to deploy during the surge.

June 24, 2020

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.

July 31, 2019

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.

July 10, 2019

Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals.

July 10, 2019

Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety.

June 5, 2019

Type 1 diabetes defined by severe insulin deficiency occurs after 30 years of age and is commonly treated as type 2 diabetes.

May 22, 2019

What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.

May 8, 2019

A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people.

April 10, 2019

In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States.

March 13, 2019

Quality improvement priorities for safer out-of-hours palliative care: lessons from a mixed-methods analysis of a national incident-reporting database.

February 6, 2019

Association of adverse effects of medical treatment with mortality in the United States: a secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors study.

January 30, 2019

Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.

November 28, 2018

Incidence and method of suicide in hospitals in the United States.

October 31, 2018

Adverse drug events and medication problems in "Hospital at Home" patients.

October 10, 2018

Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study.

June 13, 2018

Safer healthcare at home: detecting, correcting and learning from incidents involving infusion devices.

April 18, 2018

Threats to patient safety in primary care reported by older people with multimorbidity: baseline findings from a longitudinal qualitative study and implications for intervention.

January 24, 2018

Intravenous fluid prescribing errors in children: mixed methods analysis of critical incidents.

December 13, 2017

An ethnographic study of health information technology use in three intensive care units.

August 30, 2017

Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data.

August 2, 2017

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study.

June 21, 2017

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.

June 14, 2017

Prognosis of undiagnosed chest pain: linked electronic health record cohort study.

April 19, 2017

Effect of day of the week on short- and long-term mortality after emergency general surgery.

April 5, 2017

Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.

February 8, 2017

Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study.

December 14, 2016

Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data.

December 7, 2016

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

December 7, 2016

See More About The Topic

Hospitals

Health Care Providers

Health Care Executives and Administrators

Epidemiology of Errors and Adverse Events

Error Analysis

Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site