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Exploring the causes of adverse events in hospitals and potential prevention strategies
  1. M Smits1,
  2. M Zegers1,
  3. P P Groenewegen1,2,
  4. D R M Timmermans3,
  5. L Zwaan3,
  6. G van der Wal3,
  7. C Wagner1,3
  1. 1NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
  2. 2Department of Sociology and Department of Human Geography, Utrecht University, Utrecht, The Netherlands
  3. 3EMGO Institute, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
  1. Correspondence to Marleen Smits, NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN Utrecht, The Netherlands; m.smits{at}


Objectives To examine the causes of adverse events (AEs) and potential prevention strategies to minimise the occurrence of AEs in hospitalised patients.

Methods For the 744 AEs identified in the patient record review study in 21 Dutch hospitals, trained reviewers were asked to select all causal factors that contributed to the AE. The results were analysed together with data on preventability and consequences of AEs. In addition, the reviewers selected one or more prevention strategies for each preventable AE. The recommended prevention strategies were analysed together with four general causal categories: technical, human, organisational and patient-related factors.

Results Human causes were predominantly involved in the causation of AEs (in 61% of the AEs), 61% of those being preventable and 13% leading to permanent disability. In 39% of the AEs, patient-related factors were involved, in 14% organisational factors and in 4% technical factors. Organisational causes contributed relatively often to preventable AEs (93%) and AEs resulting in permanent disability (20%). Recommended strategies to prevent AEs were quality assurance/peer review, evaluation of safety behaviour, training and procedures. For the AEs with human and patient-related causes, reviewers predominantly recommended quality assurance/peer review. AEs caused by organisational factors were considered preventable by improving procedures.

Discussion Healthcare interventions directed at human causes are recommended because these play a large role in AE causation. In addition, it seems worthwhile to direct interventions on organisational causes because the AEs they cause are nearly always believed to be preventable. Organisational factors are thus relatively easy to tackle. Future research designs should allow researchers to interview healthcare providers that were involved in the event, as an additional source of information on contributing factors.

  • Adverse event
  • cause
  • prevention
  • record review
  • hospital
  • medical error
  • patient safety

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  • Funding The Dutch Patient Safety Research Program has been initiated by the Dutch Society of Medical Specialists (in Dutch: Orde van Medisch Specialisten) with financial support from the Ministry of Health, Welfare and Sport. The Program is carried out by EMGO Institute/VUmc and NIVEL.

  • Competing interests None.

  • Ethics approval The project and methods had been granted ethical approval by VU University Medical Centre in Amsterdam, The Netherlands.

  • Provenance and peer review Not commissioned; externally peer reviewed.