Joel S. Weissman, PhD; Eric C. Schneider, MD, MSc; Saul N. Weingart, MD, PhD; Arnold M. Epstein, MD, MA; JoAnn David-Kasdan, RN, MS; Sandra Feibelmann, MPH; Catherine L. Annas, JD; Nancy Ridley, MS; Leslie Kirle, MPH; Constantine Gatsonis, PhD
Acknowledgment: The authors thank Jack Fowler, PhD; Brian Clarridge, PhD; and Dragana Bolcic-Jankovic, MA, for help and support with questionnaire design and administration, and Nancy Wong for assistance with data analysis and programming.
Grant Support: By a cooperative agreement from the Agency for Healthcare Research and Quality to the Massachusetts Department of Public Health (U18 HS11928).
Potential Financial Conflicts of Interest:Grants received: J.S. Weissman (Agency for Healthcare Research and Quality), E.C. Schneider (Agency for Healthcare Research and Quality), S.N. Weingart (Agency for Healthcare Research and Quality), A.M. Epstein (Agency for Healthcare Research and Quality), J. David-Kasdan (Agency for Healthcare Research and Quality), S. Feibelmann (Agency for Healthcare Research and Quality), C.L. Annas (Agency for Healthcare Research and Quality), N. Ridley (Agency for Healthcare Research and Quality), L. Kirle (Agency for Healthcare Research and Quality).
Reproducible Research Statement:Studyprotocol and data set: Available from Dr. Weissman (e-mail, firstname.lastname@example.org). Statistical code: Not available.
Requests for Single Reprints: Joel S. Weissman, PhD, Massachusetts Executive Office of Health and Human Services, One Asburton Place, Room 1109, Boston, MA 02108; e-mail, email@example.com.
Current Author Addresses: Dr. Weissman: Massachusetts Executive Office of Health and Human Services, One Ashburton Place, Room 1109, Boston, MA 02108.
Drs. Schneider and Epstein: Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
Dr. Weingart: Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115.
Ms. David-Kasdan and Ms. Feibelmann: Institute for Health Policy, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114.
Ms. Annas: Eastern Massachusetts Healthcare Initiative, 14 Story Street, 2nd Floor, Cambridge, MA 02138.
Ms. Ridley: Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108.
Ms. Kirle: Tufts Medical Center, 800 Washington Street, Boston, MA 02111.
Dr. Gatsonis: Brown University, Center for Statistical Sciences, Box GS-121, Providence, RI 02912.
Author Contributions: Conception and design: J.S. Weissman, E.C. Schneider, S.N. Weingart, A.M. Epstein, C.L. Annas, N. Ridley, L. Kirle, C. Gatsonis.
Analysis and interpretation of the data: J.S. Weissman, E.C. Schneider, S.N. Weingart, A.M. Epstein, J. David-Kasdan, L. Kirle.
Drafting of the article: J.S. Weissman, J. David-Kasdan, S. Feibelmann, N. Ridley, L. Kirle.
Critical revision of the article for important intellectual content: J.S. Weissman, E.C. Schneider, S.N. Weingart, A.M. Epstein, J. David-Kasdan, S. Feibelmann, C.L. Annas, N. Ridley.
Final approval of the article: J.S. Weissman, E.C. Schneider, S.N. Weingart, A.M. Epstein, J. David-Kasdan, S. Feibelmann.
Statistical expertise: C. Gatsonis.
Obtaining of funding: J.S. Weissman, A.M. Epstein, N. Ridley, L. Kirle, C. Gatsonis.
Administrative, technical, or logistic support: J.S. Weissman, S.N. Weingart, J. David-Kasdan, S. Feibelmann.
Collection and assembly of data: J.S. Weissman, J. David-Kasdan.
Weissman J., Schneider E., Weingart S., Epstein A., David-Kasdan J., Feibelmann S., Annas C., Ridley N., Kirle L., Gatsonis C.; Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not?. Ann Intern Med. 2008;149:100-108. doi: 10.7326/0003-4819-149-2-200807150-00006
Download citation file:
Published: Ann Intern Med. 2008;149(2):100-108.
Improvements in patient safety depend in part on the ability to measure and monitor injuries to patients. The Institute of Medicine has called for building a national health information infrastructure that would include data about adverse events (1), but we lack consensus about the best way to measure adverse events.
Common options for reporting adverse events include voluntary and mandatory reporting by providers, automated surveillance of clinical data, administrative data, and record review. Each of these methods has weaknesses (1–4). The medical record is often preferred because of its rich clinical content, but medical record review is expensive, documentation can vary among different clinical settings, and underreporting may occur because of concern about medicolegal liability (5).
Daniel R Longo
Virginia Commonwealth University School of Medicine
July 15, 2008
Eight Years After IOM Report: Patient Reports more Reliable than Hospitals
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.
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
Madeleine C. Blaurock
July 18, 2008
Comparing Patient-Reported Hospital Adverse Events with Medical Record Review
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.
to gain full access to the content and tools.
Learn more about subscription options.
Register Now for a free account.
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only