IMPORTANCE Accurately and routinely identifying factors contributing to inpatient mortality remains challenging. OBJECTIVE To describe the development, implementation and performance of a new electronic mortality review method 1 year after implementation. METHODS An analysis of data gathered from an electronic instrument that queries front-line providers on their opinions on quality and saf...

OBJECTIVE Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare. DESIGN A study using retrospective record review and trigger ...

Introduction Monitoring hospital mortality using retrospective case record review (RCRR) is being adopted throughout the National Health Service (NHS) in England with publication of estimates of avoidable mortality beginning in 2017. We describe our experience of reviewing the care records of inpatients who died following admission to hospital in four acute hospital NHS Foundation Trusts in the...

To compare the proportion, seriousness, preventability of adverse drug events (ADEs) between the older adults (≥ 65 years old) and younger adults (<65 years old) presenting to the emergency department (ED), we conducted a prospective observational cohort study of patients 18 years and older presenting to the ED. For all ED visits between March 1, 2009, and Feb 28, 2010, investigators identified...

Medication errors are the second most common cause of adverse patient safety incidents and the single most common preventable cause of adverse events in medical practice. Given the high human fatalities and financial burden of medication errors for healthcare systems worldwide, reducing their occurrence is a global priority. Therefore, appropriate policies to reduce medication errors, using nat...

INTRODUCTION There is an increasing need to assess the value of safety improvements to society. Concerns exist, however, as to what extent standard health economic methods appropriately reflect this value because these methods do not typically incorporate the non-health or extra-consequentialist value of avoiding healthcare incidents, which may--for example, be associated with a decreased trust...