[Adverse events management. Methods and results of a development project].
BACKGROUND
This article describes the methods and results of a project in the Copenhagen Hospital Corporation (H:S) on preventing adverse events. The aim of the project was to raise awareness about patients' safety, test a reporting system for adverse events, develop and test methods of analysis of events and propagate ideas about how to prevent adverse events.


METHODS
H:S developed an action plan and a reporting system for adverse events, founded an organization and developed an educational program on theories and methods of learning from adverse events for both leaders and employees.


RESULTS
During the three-year period from 1 January 2002 to 31 December 2004, the H:S staff reported 6011 adverse events. In the same period, the organization completed 92 root cause analyses. More than half of these dealt with events that had been optional to report, the other half events that had been mandatory to report.


CONCLUSIONS
The number of reports and the front-line staff's attitude towards reporting shows that the H:S succeeded in founding a safety culture. Future work should be centred on developing and testing methods that will prevent adverse events from happening. The objective is to suggest and complete preventive initiatives which will help increase patient safety.
Rabøl
Louise Isager
LI
H:S Hvidovre Hospital, H:S Enhed for Patientsikkerhed, Hvidovre.
Jensen
Elisabeth Brøgger
EB
Hellebek
Annemarie H
AH
Pedersen
Beth Lilja
BL
D003718:Denmark; D003951:Diagnostic Errors / Q000517:prevention & control; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control; D008318:Malpractice; D019221:Mandatory Reporting; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D008508:Medication Errors / Q000517:prevention & control; D008510:Medication Systems, Hospital / Q000592:standards; D010564:Personnel, Hospital / Q000193:education; D012308:Risk Management / Q000379:methods* / Q000458:organization & administration; D017751:Safety Management / Q000379:methods* / Q000458:organization & administration