Exploring the causes of adverse events in British NHS hospital practice.

Neale, G., Woloshynowych, M. and Vincent, C. 2001. Exploring the causes of adverse events in British NHS hospital practice. Journal of the Royal Society of Medicine. 94, pp. 322-220. https://doi.org/10.1177/014107680109400702

TitleExploring the causes of adverse events in British NHS hospital practice.
TypeJournal article
AuthorsNeale, G., Woloshynowych, M. and Vincent, C.
Abstract

In a previous paper we reported that 10.8% of patients admitted to two large hospitals in Greater London experienced one or more adverse events, of which half were deemed preventable. Here we examine the underlying causes of errors in clinical practice. Rather than identifying specific errors made by individuals, we have looked at possible faults in the organization of care. Adverse events were grouped according to stages in the care process: diagnosis, preoperative assessment and care, operative or invasive procedure (including anaesthesia), ward management, use of drugs and intravenous fluids and discharge from hospital.

Less than 20% of preventable adverse events were directly related to surgical operations or invasive procedures and less than 10% to misdiagnoses. 53% of preventable adverse events occurred in general ward care (including initial assessment and the use of drugs and intravenous fluids) and 18% in care at the time of discharge. Probable contributory factors in these errors included dependence on diagnoses made by inexperienced clinicians, poor records, poor communication between professional carers, inadequate input by consultants into day-to-day care, and lack of detailed assessment of patients before discharge.

JournalJournal of the Royal Society of Medicine
Journal citation94, pp. 322-220
ISSN0141-0768
Year2001
PublisherSage
Digital Object Identifier (DOI)https://doi.org/10.1177/014107680109400702
Web address (URL)https://journals.sagepub.com/doi/abs/10.1177/014107680109400702
Publication dates
Published01 Jul 2001

Related outputs

A correlational analysis of COVID-19 incidence and mortality and urban determinants of vitamin D status across the London boroughs.
Borna, M., Woloshynowych, M., Schiano-Phan, R., Volpi, E.V. and Usman, M. 2022. A correlational analysis of COVID-19 incidence and mortality and urban determinants of vitamin D status across the London boroughs. Scientific Reports. 12 (1) 11741. https://doi.org/10.1038/s41598-022-15664-y

Obesity, oxidative DNA damage and vitamin D as predictors of genomic instability in children and adolescents
Usman, M., Woloshynowych, M., Britto, J.C., Bilkevic, I., Glassar, B., Chapman, S., Ford-Adams, M.E., Desai, A., Bain, M., Tewfik, I. and Volpi, E. 2021. Obesity, oxidative DNA damage and vitamin D as predictors of genomic instability in children and adolescents. International Journal of Obesity. 45, p. 2095–2107. https://doi.org/10.1038/s41366-021-00879-2

Food and Mood: Exploring the determinants of food choices and the effects of food consumption on mood among women in Inner London.
Leeds, J., Keith, R. and Woloshynowych, M. 2020. Food and Mood: Exploring the determinants of food choices and the effects of food consumption on mood among women in Inner London. World Nutrition. 11 (1), pp. 68-96. https://doi.org/10.26596/wn.202011168-96

Work conditions, mental workload, and patient care quality: a multisource study in the emergency department.
Weigl, M., Müller, A., Holland, S., Wedel, S. and Woloshynowych, M. 2016. Work conditions, mental workload, and patient care quality: a multisource study in the emergency department. BMJ Quality and Safety. 25, pp. 499-508. https://doi.org/10.1136/bmjqs-2014-003744

The ABC of Handover: Impact on shift handover in the Emergency Department
Farhan, M., Brown, R., Vincent, C. and Woloshynowych, M. 2012. The ABC of Handover: Impact on shift handover in the Emergency Department. Emergency Medicine Journal. 19, pp. 947-953. https://doi.org/10.1136/emermed-2011-200201

The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department.
Farhan, M., Brown, R., Woloshynowych, M. and Vincent, C. 2012. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emergency Medicine Journal. 29, pp. 941-946. https://doi.org/10.1136/emermed-2011-200199

Stress Management Training for Surgeons - a randomised controlled intervention study
Wetzel, C.M., George, A., Hanna, G.B., Athanasiou, T., Black, S.A., Kneebone, R.L., Nestel, D. and Woloshynowych, M. 2011. Stress Management Training for Surgeons - a randomised controlled intervention study. Annals of Surgery. 253 (3), pp. 488-494. https://doi.org/10.1097/SLA.0b013e318209a594

The effect of stress and coping on surgical performance during simulations
Wetzel, C.M., Black, S.A., Hanna, G.B., Athanasiou, T., Kneebone, R.L., Nestel, D., Wolfe, J.H.N. and Woloshynowych, M. 2010. The effect of stress and coping on surgical performance during simulations . Annals of Surgery. 251 (1), pp. 171-176. https://doi.org/10.1097/SLA.0b013e3181b3b2be

Communication Patterns in a UK Emergency Department
Woloshynowych, M., Davis, R., Brown, R. and Vincent, C. 2007. Communication Patterns in a UK Emergency Department. Annals of Emergency Medicine. 50 (4), pp. 407-413. https://doi.org/10.1016/j.annemergmed.2007.08.001

Patient safety and iatrogenesis
Woloshynowych, M. and Vincent, C. 2007. Patient safety and iatrogenesis. in: Ayers, S., Baum, A., McManus, C., Newman, S, Wallston, K., Weinman, J. and West, R. (ed.) Cambridge Handbook of Psychology, Health and Medicine. 2nd edition Cambridge University Press.

The effects of stress on surgical performance.
Wetzel, C. M., Kneebone, R., Woloshynowych, M., Nestel, D., Moorthy, K., Kidd, J. and Darzi, A. 2006. The effects of stress on surgical performance. The American Journal of Surgery. 191 (1), pp. 5-10. https://doi.org/10.1016/j.amjsurg.2005.08.034

Techniques used in the investigation and analysis of critical incidents in healthcare
Rogers, S, Taylor-Adams, S. and Woloshynowych, M. 2006. Techniques used in the investigation and analysis of critical incidents in healthcare. in: Walshe, K. and Boaden, R. (ed.) Patient Safety: Research into Practice Maidenhead, UK Open University Press. pp. 130-143

The investigation and analysis of critical incidents and adverse events in healthcare
Woloshynowych, M., Rogers, S., Taylor-Adams, S. and Vincent, C. 2005. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technology Assessment. 9 (19). https://doi.org/10.3310/hta9190

Retrospective case record review: a blunt instrument that needs sharpening
Neale, G. and Woloshynowych, M. 2003. Retrospective case record review: a blunt instrument that needs sharpening. BMJ Quality and Safety. 12 (1), pp. 2-3. https://doi.org/10.1136/qhc.12.1.2

Adverse events in British hospitals: preliminary retrospective record review
Vincent, C., Neale, G. and Woloshynowych, M. 2001. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 322, pp. 517-519. https://doi.org/10.1136/bmj.322.7285.517

Permalink - https://westminsterresearch.westminster.ac.uk/item/qzqz4/exploring-the-causes-of-adverse-events-in-british-nhs-hospital-practice


Share this

Usage statistics

55 total views
0 total downloads
These values cover views and downloads from WestminsterResearch and are for the period from September 2nd 2018, when this repository was created.