Patient safety in hospitals: new insight form the Dutch adverse event study.

Wagner, C., Bruyne, M.C. de, Zegers, M., Hoonhout, L., Wal, G. van der. Patient safety in hospitals: new insight form the Dutch adverse event study. In: Book of abstracts. International Conference 'Patient Safety Research shaping the European Agenda', 24-26 september 2007, Porto. p. 150.

Until now the extent and severity of preventable adverse events in Dutch hospitals are unknown. Therefore it is difficult to develop interventions which will actually decrease the number of adverse events. In various studies outside the Netherlands, it has been shown that the percentage of adverse events varies from 2. 9% of the hospita! admissions in Utah and Colorado to 16.6% of these in Australia. Of these adverse events, a quarter (France) to a half (Australia) were supposed to be avoidable (27.7-51.2%).

Despite of these al ready existing international figures, the Dutch ministry of health and the national association of medica! doctors feit that it was necessary to gain more insight into the Dutch situation in order to create the sense of urgency necessary to improve patient care. In April 2007 the Dutch figures will be presented for the first time during an invitational conference. For this conference the most important medica! associations, the ministry of health, the health care inspectorate, the association of hospitals and nurses, and the scientific researchers has been invited. The aim of the conference is to jointly agree on the necessary steps to make the Dutch health care as safe as possible for patients. Furthermore, it is expected that as a result of the conference the responsibilities of the various parties in improving patient safety will be determined and will form the basis of a patient safety improvement campaign.

The adverse event study is the first part of the Dutch national research program on patient safety. The main parts of the program are: (la) a retrospective epidemiological study in 21 hospitals into the character, severity, extent and costs of adverse events du ring hospitalization and the resulting harm to patients, (lb) a retrospective epidemiological study of adverse events du ring day-care in these hospitals, and (lc) a comparison between the adverse events of the record study, the incidents reported by professionals and the complaints reported by patients. Project 2 concerns a study at surgery departments, ER's, and departments of internal medicine into the causes of adverse events and near misses, and how to prevent these. At these wards, the role of factors relating to the organization, human factors, technica! and patient-related factors in the occurrence of adverse events and near misses is investigated and classified with the PRISMA-methodology. The study into near misses focuses on the human recovery factors preventing the incident from causing harm. Project 3 concerns a study of the patient safety culture at hospita! departments. Finally, three intervention studies has been set up.

At the conference, the results of the adverse event study of 7926 patient records of discharged or deceased patients will be presented and compared to the results of earlier international studies. In contrast to ether studies adverse event data have been analysed by multi-level-analyses which gives a more profound insight into the variation between hospitals and hospitals departments. In addition we will focus on the impact the results of the study had on hospitals, professional groups and policy makers.