Table 3

Publications of patient-reported medical errors or adverse events

StudyAuthor(s)Year of publicationFocus/PurposePopulationSettingMethod of surveyPersonal experience only or family includedNumber of responsesResponse rateTypes of errors reportedNumber of reportsNumber of incidents reported per personTimeline of reporters recallWhere/how found
Views of Practicing Physicians and the Public on Medical Errors.6Blendon RJ, DesRoches CM, Brodie M, et al.2002Physician & public views about the medical error statisticsGeneral
BroadRandom digit dialling. Open-ended & closed-ended questions.Personal & family members’120667%Reporter classified: health consequences as serious (24%), minor (13%), none (5%).507 reports of errors in own care or with family member.0.4/personEntire lifetimeReference list “Perceptions of preventable medical errors in Alberta” Northcott H, et al 200714
Developing a comprehensive electronic adverse event reporting system in an academic health centre.7Kivlahan C, Sangster W, Nelson K, et al.2002Web-based survey for staff, patients, family, & visitorsSpecific
University of Missouri Health Care discharged patients
HospitalWeb-based anonymous survey at stand-alone stations in hospital or online for access from home.
Open-ended questions.
Personal345Could not be calculatedReporter classified: compliments, complaints, or suggestions.345 comments.Not reportedRecent experienceDatabase MEDLINE
Patient-reports of preventable problems and harms in primary health care.8Kuzel AJ, Woolf SH, Gilchrist VJ, et al.2004Patients identifying harmful preventable incidentsGeneral
Virginia & Ohio rural, suburban, & urban public
Primary CareRandom digit dialling to recruit. In person interview. $50 incentive to participate in interview.
Open-ended, prompted narratives.
Personal38Could not be calculatedClinician classified: access breakdown (28.5%), communication breakdown (7.7%), relationship breakdown (37.1%), technical error (24.4%), inefficiency of care (2.3%). Harm (76.9%) classified into psychological & physical.221 reported problematic incident.5.8/personEntire lifetimeDatabase MEDLINE
Patient reports of undesirable events during hospitalization.9Agoritsas T, Bovier PA, Perneger TV.2005Events patients identify; comparing overall satisfaction rating with problems encounteredSpecific Geneva University Hospital discharged patientsHospitalWritten questionnaire mailed out as 2001 routine patient opinion survey.
Closed-ended questions.
Personal143367%Reporter classified: medical complications (23.5%), interpersonal problems (29.9%), incidents related to the health care process (23.5%).1814 total undesirable events; 725 (50.6%) reported at least 1 event.1.3/personMost recent hospitalisationDatabase PubMed
What can hospitalized patients tell us about adverse events? Learning from patient-reported incident?3Weingart SN, Pagovich O, Sands DZ, et al.2005Inpatients identify adverse eventsSpecific: Boston teaching hospital medical unit- inpatientsHospitalIn-person interviews (open-ended questions). Follow-up phone interviews 10 days after discharge (open-ended questions).Personal52886%Clinician classified: adverse events (7.5%), near misses (3.5%), & medical errors with minimal risk of harm (9.2%). Positive/favourable assessments of care (24.2%). Service quality problems (55.8%).310 distinct incident reports received. 112 patients reported at least 1 incident.1.4/personMost recent hospitalisationDatabase MEDLINE
Reports of Preventable Medical Errors from the Alberta Patient Safety Survey 2004.10Vanderheyden LC, Northcott HC, Adair CE, et al.2005Survey to assess perceptions & personal experience with preventable medical errorsGeneral
BroadRandom digit-dialling for households. Computerised-assisted phone interviewing system.
Closed-ended & open-ended questions, narratives.
Personal & household members150055%Researcher classified: clinical performance (23.7%), medication (22.8%), diagnosis (22.4%), communication (13.5%), other (17.6%, patient management, time, surgery, therapy, practitioner attitude or disposition, no improvement in condition, inefficiency with time or resources, & lack of procedures).559 total reports of personal or family member experiencing a preventable medical error.0.4/personEntire life in AlbertaDatabase PubMed
Consumer perceptions of safety in hospitals.11Evans SM, Berry JG, Smith BJ, et al.2006Safety of Australian hospitalsGeneral
Adelaide, South Australia & rural centres with population exceeding 1000
HospitalIn-person interview. Closed-ended questions.Personal & household members2884 representing 8068 persons78%Reporter classified: severity (really serious (59.7%), a little serious, notserious), prolonged hospitalisation (48.5%).170 respondents reported 240 adverse events amongst household members.0.1/personIn last 5 yearsDatabase PubMed
Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients.12Phillips RL, Dovey SM, Graham D, et al.2006To compare reports of medical errors made by family doctors, office staff, & patientsSpecific
10 American Academy of Family Physicians National Research Network family clinics
Primary CareAnonymous reports via web site, paper forms, & voice-activated phone system.
Closed-ended & open-ended questions, narratives.
Personal126Could not be calculatedReporter classified: Process errors, & knowledge & skill errors including extended waiting (33.3%), errors in past (16.7%), mistaken identity (11.1%), unnecessary blood draw (5.6%), prescription (5.6%), other (27.1%).126 patients reported 18 errors (10 mail; 7 web; 1 phone)0.1/personRecent primary care visitReference list “Rural community members’ perception of harm from medical mistakes: A High Plains Research Network study” Rebecca VanVorst 200713
Rural community members’ perception of harm from medical mistakes: A High Plains Research Network study.13Van Vorst RF, Araya-Guerra R, Felzien M, et al.2007To learn about rural community members’ definitions & types of harm from medical mistakesGeneral
4 rural north-eastern Colorado communities
BroadSurveys inserted in 4 local newspapers. Community advisory council members distributed 25 additional surveys.
Open-ended questions.
Personal & family members2863%Clinician classified: obvious medical mistakes (30%), possible mistakes (29%), problems or unanticipated outcomes (41%). Obvious mistakes classified further: clinical event (62%), communication errors (23%), & medication errors (23%).Total 180 incidents. 172 reports of at least one medical mistake involving respondent or family member.0.6/personEntire life-timeDatabase PubMed
Perceptions of preventable medical errors in Alberta, Canada.14Northcott H, Vanderheyden L, Northcott J, et al.2007Comparing patients who report personal or family experience of preventable medical errors with the perceptions of patients who did not report first-hand experienceGeneral
BroadRandom digit-dialling. Computerised-assisted phone interviewing system.
Closed-ended & open-ended questions, narratives.
Personal & household members150055%Researcher classified: clinical performance (23.7%), medication (22.8%), diagnosis (22.4%), communication (13.5%), other (17.6%, including patient management, time, surgery, therapy, practitioner attitude or disposition, no improvement in condition, inefficiency with time or resources, & lack of procedures).559 total reports. 37.3% of patients reported that they or a family member had experienced a preventable medical error. 32% reported error in personal care, 56% in a family member's care, & 12% in both.0.4/personEntire life in AlbertaDatabase MEDLINE
Patient-reported safety and quality of care in outpatient oncology.15Weingart SN, Price J, Duncombe D, et al.2007Oncology patients observe & report unsafe experiencesSpecific Boston cancer centre inpatientsOncologyInterviewed in-person by patient-advocates.
Open-ended questions.
Personal19396%Reporter classified: adverse events (1.6%), close calls (3.3%), errors without risk or ham (11.6%), service quality incidents (83.5%).138 comments about safety or general care. Only coded 121 reports affecting 83 patients.1.4/personRecent treatment at cancer centreDatabase PubMed
Patients use an internet technology to report when things go wrong.16Wasson JH, MacKenzie TA, Hall M.2007Evaluating accuracy of patient reported medical errors & an electronic reporting surveyGeneral
BroadHealth survey online.
Customised health & self-management resources as incentive. Open-ended & closed-ended questions.
Personal & family members44,860Not reportedLawyer classified: nuisance (91%) & potential compensable injury (9%).610 reports of health-related adverse event (2979 reports of harm, hurt, or injury to themselves or a family member over lifetime).Less than 0.1/personPrevious yearDatabase PubMed
“Against the silence”: Development and first results of a patient survey to assess experiences of safety-related events in hospital.17Schwappach DLB.2008Develop & pilot test patient safety survey for inpatientsSpecific
2 Swiss hospital general surgical & internal medicine discharged patients
HospitalIn-patient or discharged written questionnaire (closed-ended questions). Follow-up phone interview (open-ended questions).Personal125- with 18 follow up interviews31%Researcher classified: process of care (39.8%), medication (30.5%), communication (25%), fall (4.6%). Definitive (73.4%) or uncertain (26.6%)128 reports.1.0/personRecent hospital stayDatabase PubMed
Can Patient Safety Be Measured by Surveys of Patient Experiences?18Solberg LI, Asche SE, Averbeck BM,et al.2008To determine whether patient reports of medical errors can be used to measure safetyLarge multi-speciality medical group located in Minneapolis-St. PaulSpecialty and Primary CareMailed questionnaire.
Open ended.
Personal & family1,99865%Reporter classified: wrong diagnosis, wrong treatment, wrong prescription, wrong procedure, or other.
Clinician classified: medical error (10%), non-medical error (9%), behaviour / communication (20%), misunderstanding (45%), inadequate information (13%), unable to determine (3%)
247 reports12.4/familyPrevious yearColleague recommendation
Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not?19Weissman JS, Schneider EC, Weingart SN, et al.2008To compare adverse events reported in postdischarge patient interviews with adverse events detected by medical record review.Massachusetts HospitalsHospitalTelephone interview. Combination open and closed ended questions.Personal258262%Clinician classified: severity (life-threatening (1%), serious (13%), clinically significant (63%), or trivial or insignificant (23%)) and preventability (definitely (1%), probably (29%), probably not (68%), or definitely not (3%))253 reports0.3 events / personApril 1 – October 1, 2008Colleague recommendation
Medication safety messages for patients via the web portal: The MedCheck intervention.20Weingart SN, Hamrick HE, Tutkus S.2008To determine whether electronic medication safety messages can improve communication about medications and identify ADEs.Specific:
Three adult sites
Primary careElectronic messages delivered via web portal.
Open ended.
Personal182112%Reporter classified: problems filling prescriptions (48%), problems with drug effectiveness (12%), and medication symptoms (10%).170.06 events / personApril 1, 2001 - June 10, 2002Colleague recommendation
Adverse Drug Events in Ambulatory Care21Gandhi TK, Weingart SN, Borus J, et al.2003To determine the rates, types, severity, and preventability of adverse drug events among outpatients and to identify preventive strategies.Specific:
Four adult practices
Primary careTelephone interview.
Combination open and closed ended questions.
Personal66155%Clinician classified:
Serious (13%), ameliorable (28%), preventable (11%).
Of ameliorable events, 63% due to physician's failure to respond to medication-related symptoms, and 37% due to patient's failure to inform physician.
1810.27 events/personSeptember 1999 – March 2000Colleague recommendation