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Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study |
Mayor S, Baines E, Vincent C, Lankshear A, Edwards A, Aylward M, Hogan H, Harper P, Davies J, Mamtora A, Brockbank E & Gray J |
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Record Status This is a bibliographic record of a published health technology assessment from a member of INAHTA. No evaluation of the quality of this assessment has been made for the HTA database. Citation Mayor S, Baines E, Vincent C, Lankshear A, Edwards A, Aylward M, Hogan H, Harper P, Davies J, Mamtora A, Brockbank E & Gray J. Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study. Health Services and Delivery Research 2017; 5(9) Authors' objectives Despite global activity over the past 15 years to improve patient safety, the measurement of adverse events (AEs) remains challenging.
The two-stage retrospective review methodology was used to quantify harm across NHS Wales. In total, 4536 inpatient episodes were screened for AEs by research nurses. Records that were highly suggestive of AEs were further assessed by physicians. NHS-led teams undertook GTT reviews on the same case notes. Authors' conclusions The extent of harm detected across NHS Wales using both the two-stage retrospective review process and the new Harm2 tool conforms to the findings in the literature, but this is the first longitudinal study using these methods. With training and using a structured review process, non-physician reviewers can undertake case note review efficiently and effectively, and the rates of AEs and of the preventability and the breakdown of problems in care conform to those reported in studies in which physicians undertake these classifications. Whether the patient died or was discharged alive significantly influences the rate and composition of AEs. The Harm2 tool performed with moderate reliability in the determination of AEs. Indexing Status Subject indexing assigned by CRD MeSH Humans; Medical Errors; Quality Improvement Language Published English Country of organisation England English summary An English language summary is available. Address for correspondence HS&DR Programme, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Alpha House, Enterprise Road, Southampton, SO16 7NS, UK Tel: +44 23 8059 4304
Email: hsdrinfo@southampton.ac.uk AccessionNumber 32017000157 Date abstract record published 16/03/2017 |
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