Adverse events and near misses relating to information management in a hospital.
OBJECTIVE
This study described information management incidents and adverse event reporting choices of health professionals.


METHODS
Hospital adverse events reported in an anonymous electronic reporting system were analysed using directed content analysis and descriptive and inferential statistics. The data consisted of near miss and adverse event incident reports (n = 3075) that occurred between January 2008 and the end of December 2009.


RESULTS
A total of 824 incidents were identified. The most common information management incident was failure in written information transfer and communication, when patient data were copied or documented incorrectly. Often patient data were transferred using paper even though an electronic patient record was in use. Reporting choices differed significantly among professional groups; in particular, registered nurses reported more events than other health professionals.


CONCLUSIONS
A broad spectrum of information management incidents was identified, which indicates that preventing adverse events requires the development of safe practices, especially in documentation and information transfer.
University of Eastern Finland, Finland virpi.jylha@hotus.fi.
Virpi
V
Jylhä
Brigham and Women's Hospital, USA Harvard Medical School, USA Harvard School of Public Health, USA.
David W
DW
Bates
University of Eastern Finland, Finland.
Kaija
K
Saranto
D057286:Electronic Health Records; D006751:Hospital Information Systems / Q000458:organization & administration*; D006785:Hospitals, University; D006801:Humans; D019451:Information Management; D008485:Medical Audit; D019300:Medical Errors / Q000517:prevention & control
communication; healthcare; hospital information systems; hospitals; information management; medical errors; medication errors; patient safety; risk management