OBJECTIVE To investigate the nature of process failures in postoperative care, to assess their frequency and preventability, and to explore their relationship to adverse events. BACKGROUND Adverse events are common and are frequently caused by failures in the process of care. These processes are often evaluated independently using clinical audit. There is little understanding of process failu...

IMPORTANCE Venous thromboembolism (VTE) is a major cause of morbidity and mortality among hospitalized patients and is largely preventable. Strategies to decrease the burden of VTE have focused on improving clinicians' prescribing of prophylaxis with relatively less emphasis on patient education. OBJECTIVE To develop a patient-centered approach to education of patients and their families on V...

The aims of this study were to describe fatal and non-fatal self-harm burdens, as well as burdens from the main preventable risk factors, and to investigate the different suicide methods in Hubei province in central China utilizing data from both Global Burden of Disease Study 2015 and Hubei Disease Surveillance Points system. All self-harm burdens including mortality, years of life lost (YLLs)...

OBJECTIVE Venous thromboembolism is associated with substantial morbidity and mortality and is largely preventable. Despite this fact, appropriate prophylaxis is vastly underutilized. To improve compliance with best practice prophylaxis for VTE in hospitalized trauma patients, we implemented a mandatory computerized provider order entry-based clinical decision support tool. The system required ...

OBJECTIVES An efficient and reliable process for measuring harm due to medical care is needed to advance pediatric patient safety. Several pediatric studies have assessed the use of trigger tools in varying inpatient environments. Using the Institute for Healthcare Improvement's adult-focused Global Trigger Tool as a model, we developed and pilot tested a trigger tool that would identify the mo...

In response to a weight of evidence that patients are frequently harmed as a result of their care, there have been concerted efforts to make healthcare safer, with health systems across the globe investing significant resources in policies and programmes designed to reduce adverse events. Yet, despite extensive efforts, improvements in safety have proved difficult to sustain and spread, with st...

OBJECTIVES To describe the pattern of preventable in-hospital medical injury under the "no fault" system and to assess the level of serious preventable patient harm. DESIGN Cross sectional survey using a two stage retrospective assessment of medical records conducted by structured implicit review. SETTING General hospitals with over 100 beds providing acute care in New Zealand. PARTICIPAN...

OBJECTIVE To determine the change in adverse event (AE) rates and preventable AE rates over time, identify certain patient risk groups and discuss factors influencing the outcome. DESIGN Longitudinal retrospective patient record review study. SETTING AND PARTICIPANTS A random sample of 21 hospitals in The Netherlands in 2004, and 20 hospitals in 2008. In each hospital, 400 patient admission...

OBJECTIVE To determine rates and types of adverse drug events (ADEs) in the pediatric ambulatory setting. METHODS A prospective cohort study at 6 office practices in the greater Boston area was conducted over 2-month periods. Duplicate prescription review, telephone surveys 10 days and 2 months after visit, and chart reviews were done. A 2-physician panel classified the severity, preventabili...