Epidemiology of Patient Safety Events in an Academic Teaching Hospital

Ciera Leeder, Université D'Ottawa / University Of Ottawa, Université D'Ottawa / University Of Ottawa
2016
Adverse events are poor health outcomes caused by medical care rather than the underlying disease process. Voluntary reporting is a key component to adverse event reduction; however, incident reporting systems contain many limitations. The Patient Safety Learning System (PSLS) is an electronic incident reporting system with several unique features that were designed to address the weaknesses of previous systems, including a process for physician assessment of reported events to determine their
more » ... to determine their significance. The primary objectives for this study were to determine the positive predictive value of the PSLS for identifying adverse events. Secondary objectives were to identify event, patient, and system-level factors associated with true events, and to assess event rates over time. Methods: I performed a retrospective cohort study using electronic health care data collected data from the Ottawa Hospital, between April 1 2010 and September 30, 2011. We Included all reported patient safety events if they occurred in adults aged 18 and older, admitted to an inpatient ward at the Civic, General, or Heart Institute campus. Events that occurred on Psychiatry, Rehabilitation services, were excluded due to data restrictions. A Clinical Reviewer manually reviewed each event to distinguish true events from non-events. For each hospital program, we used a generalized linear mixed model (GLIMMIX) to predict true events, using the role of the reporter as a random effect. Results: Over the study period, there were 2,569 events reported by hospital staff and physicians. Of these, 660 were rated as adverse events and 1,909 were rated as near misses. This yielded an overall positive predictive value of the PSLS system of 63% (95% CI 62-65%). The variance between reporters was not significant for Critical Care, Heart Institute, Nephrology, Obstetrics and Gynecology, Surgery and Periops, therefore I used a traditional logistic regression model with a common intercept. Number of months the PSLS was available was the only sign [...]
doi:10.20381/ruor-5227 fatcat:hcqfzbqwundxdhkq23u3zf7y3a