Table 4

Areas of effort to prevent recurrence of in-hospital preventable adverse events with serious patient impact*†

Area of effort‡No. of AEs% of 48 AEs affected% of 113 AE mentions§
AE = adverse event.
*Incident recorded by healthcare professional during sampled admission and later assessed as adverse event by study physician reviewer; any evidence of healthcare management causation; occurred inside a public hospital; any evidence of preventability; and permanent disability or death.
†Percentages and 95% confidence intervals have been adjusted to account for stratified cluster sample design.
‡MO reviewers assessed potential for prevention of recurrence of AEs by identifying broad “areas of effort”. More than one area could be mentioned for an AE (see also box 2).
§The category of “mention” combines the counts derived from the various areas of effort (see previous note). The total number of mentions is therefore greater than the total number of AEs.
¶ Includes changes in management/culture and better record keeping.
**Includes credentialling and retraining.
††Includes more or better personnel and equipment/physical resources.
(A) Communication, better access to/transfer of information1429.814.3
(B) New, better or better implemented policies/protocols1221.69.2
(C) Organisational factors¶1020.912.2
A and/or B and/or C = total system affected2448.6 (33.9 to 63.2)35.7 (28.5 to 42.8)
Consultation with specialists/peers2858.0 (38.4 to 77.5)24.7 (15.7 to 33.7)
Education1430.1 (18.1 to 42.1)12.8 (8.6 to 17.0)
Other**1124.3 (11.7 to 36.9)12.4 (7.4 to 17.2)
Resources††918.5 (2.2 to 34.9)8.8 (2.4 to 15.4)
Quality assurance613.1 (4.0 to 22.2)5.6 (2.3 to 8.9)
Total100 (n=113)
In-hospital preventable and serious subset: AE occurrence rate0.7% (48/6, 579)