REPLY
Preventing Adverse Events
Laura A. Petersen;
Troyen A. Brennan; and
Thomas H. Lee
15 June 1995 | Volume 122 Issue 12 | Pages 962-964
IN RESPONSE:
Drs. Berg and Bielefeldt have overlooked information provided in our article that addresses the issue of reporting bias. As noted in the article [1], we reviewed medical records of all 3146 admissions during the study period using the methods of the Medical Practice Study [2, 3]. Only 14 preventable adverse events that had been unreported by the housestaff were detected by this record review, and 50% of these occurred during periods of cross-coverage by an intern from another team or by the night float physician. Therefore, comprehensive record review of all admissions does not suggest reporting bias.
We agree with the authors of these letters that cross-coverage periods differ from usual working hours in several ways beyond cross-coverage itself. However, the data for the matched controls regarding coverage status were collected at the same time the potentially preventable adverse events occurred in the cases. The control patients were thus subjected to the same circumstances (for example, fewer residents per intern) as were the cases but differed in having lower rates of cross-coverage.
Dr. O'Mahony misinterprets our discussion by describing our conclusion as a condemnation of decreased housestaff hours. We agree that the focus of current discussions should be on how to improve communication during cross-coverage periods and agree with the assertion of Dr. Casner that supervision of housestaff is a critical issue.
Finally, Dr. Berg's assertion that "the authors' motives must be questioned" is contrary to the collection of quantitative data on this issue. This project was conceived and performed by housestaff in the spirit of continuous quality improvement. The first author was a senior resident during the data collection period, and the participation rate of 91% is evidence of the involvement by the housestaff. Our data led to improvements in the cross-coverage system at our own institution. We continue to believe that the effect of redesigns on our health care system should be evaluated rigorously, even if we believe a priori that the changes are for the better.
1. Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does house-staff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994; 121:866-72.
2. O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. A comparison of physician self-reporting with medical record review to identify medical adverse events. Ann Intern Med. 1993; 119:370-6.
3. Brennan TA, Leape LL, Laird NM, Herbert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients—results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370-6.
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