Adverse event reporting and patient safety at a University Hospital: Mapping, correlating and associating events for a data-based patient risk management.
BACKGROUND
Reporting adverse events (AE) with a bearing on patient safety is fundamentally important to the identification and mitigation of potential clinical risks.


OBJECTIVE
The aim of this study was to analyze the AE reporting systems adopted at a university hospital for the purpose of enhancing the learning potential afforded by these systems.


METHODS
Retrospective cohort study


METHODS
Data were collected from different information flows (reports of incidents and falls, patients' claims and complaints, and cases of hospital-acquired infection [HAI]) at an university hospital. A composite risk indicator was developed to combine the data from the different flows. Spearman's nonparametric test was applied to investigate the correlation between the AE rates and a Poisson regression analysis to verify the association among characteristics of the wards and AE rates.


METHODS
Sixty-four wards at a University Hospital.


RESULTS
There was a marked variability among wards AE rates. Correlations emerged between patients' claims with complaints and the number of incidents reported. Falls were positively associated with average length of hospital stay, number of beds, patients' mean age, and type of ward, and they were negatively associated with the average Cost Weight of the Diagnosis-related group (DRG) of patients on a given ward. Claims and complaints were associated directly with the average DRG weight of a ward's patient admissions.


CONCLUSIONS
This study attempted to learn something useful from an analysis of the mandatory (but often little used) data flows generated on adverse events occurring at an university hospital with a view to managing the associated clinical risk to patients.
Department of Molecular Medicine, Laboratory of Public Health and Population Studies, University of Padua, Padua, Italy.
Alessandra
A
Buja
Padua University Hospital, Padua, Italy.
Anna Maria
AM
Saieva
Padua University Hospital, Padua, Italy.
Angela
A
Vinelli
Padua University Hospital, Padua, Italy.
Rosaria Manola
RM
Cacco
Padua University Hospital, Padua, Italy.
Ketty
K
Ottolitri
School of Medicine, University of Padua, Padua, Italy.
Elisa
E
De Battisti
Padua University Hospital, Padua, Italy.
Claudio
C
Dario
Department of Molecular Medicine, Laboratory of Public Health and Population Studies, University of Padua, Padua, Italy.
Vincenzo
V
Baldo
D000058:Accidental Falls / Q000706:statistics & numerical data; D000367:Age Factors; D003428:Cross Infection / Q000453:epidemiology; D004282:Documentation; D006742:Hospital Bed Capacity / Q000706:statistics & numerical data; D006785:Hospitals, University / Q000191:economics / Q000458:organization & administration*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D061214:Patient Safety; D012189:Retrospective Studies; D012308:Risk Management / Q000458:organization & administration; D017751:Safety Management / Q000191:economics / Q000458:organization & administration*
Patient safety; adverse events; epidemiology and detection; measurement/epidemiology; medical error; risk management; safety culture