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1. Comparing Patient-Reported Hospital Adverse Events with Medical Record Review

   • Madeleine C. Blaurock, MD

   TMPG
   It is interesting that 3 of the 21 serious and "preventable" adverse events identified by patient interview were DVT. In the lead article in this same issue, which studied LMWH vs. compression stockings in knee arthroscopy patients, of patients who recieved 14 days of LMWH, 4 had symptomatic VTE and 7 had asymptomatic DVT- in other words, DVT is not completely preventable. In another case, delerium is solely ascribed to electrolyte abnormalites. In my experience as a practicing hospitalist, delerium is almost always multifactorial. It is my impression that while the incidence of wound infections can be decreased, again, they are not entirely preventable.

   Conflict of Interest:

   None declared

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   Published July 21, 2008
2. Eight Years After IOM Report: Patient Reports more Reliable than Hospitals

   • Daniel R Longo, ScD

   Virginia Commonwealth University School of Medicine

   In 2005 we published a study aimed “to assess the status of hospital patient safety systems since the release of the Institute of Medicine (IOM) report, “To Err Is Human: Building a Safer Health System” (1), and to identify changes over time in a patient safety project funded by the Agency for Healthcare Research and Quality (2). This was five years after the IOM reports on medical errors and quality focused national attention on improving patient safety through changes in "systems" of care. Tremendous professional (3, 4) and popular press coverage of the IOM report and numerous interventions ensued after the concerns rose. None-the -less, we found modest improvements in all areas studied falling short of national recommendations. We urged the public to become more knowledgeable and assertive consumers of hospital care, and we asked them to support hospitals in their patient safety efforts, including provision of financial resources to put necessary systems in place.

   Weismann and colleagues recently released an article, “Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not?” (5). Now eight years after the IOM report and three years after our study and others, hospital patient safety is still a national concern with reporting of errors still a problem. Weismann and colleagues advance our knowledge substantially in finding that, indeed, patients are reporting some serious and preventable events that are not documented in the medical record. Why does this problem continue? Thus, one must wonder the extent to which hospital attorneys and others concerned with protecting hospital liability continue to persist in influencing the under-reporting of errors, especially errors that legitimately should be recorded in the medical record. A culture of silence continues while a culture of quality improvement is needed. For example, we found only 33.6 percent of hospitals had a fully implemented patient safety reporting policy, 64.8 percent had a written adverse prevention policy and 33.6 percent fully implemented a policy rewarding employees and “thanked” them for reporting patient safety problems. These issues require a change in organizational culture for change to occur. The present study also cautions those concerned with patient safety to carefully access the extent to which any study that does not take patient reporting into account as severely underestimating the extent of problems in the nation’s hospitals. Thankfully, if nothing else, patients are now more knowledgeable in understanding when things go wrong with hospital care.

   References

   1. Kohn LT, ed, Corrigan JM, ed, Donaldson MS, ed. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

   2. Longo DR, Hewett JE, Ge B, Schubert S. The long road to patient safety: a status report on patient safety systems. JAMA. 2005 Dec 14;294(22):2858-65.

   3. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293:2384-2390.

   4. Altman DE, Clancy C, Blendon RJ. Improving patient safety: five years after the IOM report. N Engl J Med. 2004;351:2041-2043.

   5. Weissman, JS, Schneider EC, Weingart SN, Epstein AM, David-Kasdan J,Feibelmann S, Annas CL, Ridley N, Kirle L, Gatsonis C. Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not? Annals of Internal Medicine.2008 July 15:149(2): 100-108

   Conflict of Interest:

   None declared

   Submit response
   Published July 15, 2008