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Causes/Types of Error

General studies of errors and adverse events


Thomas et al., forthcoming 2000

Adverse events occurred in 2.9% ± 0.2 of hospitalizations in each state. 32.6% ± 4 of adverse events were due to negligence in Utah and 27.4 ± 2.4 were due to negligence in Colorado. Death occurred in 6.6% ± 1.2 of adverse events and 8.8% ± 2.5 of negligent adverse events. The leading cause of nonoperative adverse events were adverse drug events (19.3% of all adverse events; 35.1% were negligent). Operative events comprised 44.9% of all adverse events and 16.9% were negligent.

Adverse event—''an injury caused by medical management (rather than the disease process) that resulted in either a prolonged hospital stay or disability at discharge."
Negligence was defined as "care that fell below the standard expected of physicians in their community."

46.1% of adverse events (22.3% negligent) were attributable to surgeons and 23.2% (44.9% negligent) were attributable to internists.

Bhasale et al., 1998 Analysing potential harm in Australian general practice

805 incidents were reported. 76% were preventable and 27% had potential for severe harm.

Incident—"an unintended event, no matter how seemingly trivial or commonplace, that could have harmed or did harm a patient."

Pharmacological management related to 51 per 100 incidents. Poor communication between patients and healthcare professionals and actions of others contributed to 23 per 100 incidents each. Errors in judgment contributed to 22 per 100 incidents.


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