Experience of serious adverse events and patient safety systems at hospitals

Abstract

The purpose of this study is to identify the difference of patient safety management system and the activities between acute care and long term care hospitals relating to the experience of serious adverse events, and to investigate effective support plans.

In September 2011, a questionnaire regarding the experience of serious adverse events, patient safety management system and activities was delivered to 3,890 hospitals by mail. Response rate was 32.4%. The experience of serious adverse events was related to bed size, assignment of a safety manager and use of root cause analysis (RCA) in acute care hospitals, and to use of RCA or SHELL in long term care hospitals. In acute care and long term care hospitals with the experience of serious adverse events, the assignment of a safety manager was not related to any patient safety activities. In hospitals without the experience of serious adverse events, the assignment of a safety manager was related to “use of RCA”, “manual or casebook based on reported cases”, “assignment of a person in charge of patient safety education” (in acute care hospitals only) and “patient safety education programs” (in long term care hospitals only). The assignment of a safety manager may contribute to establish patient safety management system in hospitals without the experience of serious adverse events. Among the respondents, 26.3% of acute care hospitals and 67.6% of long term care hospitals did not have the experience of serious adverse events and did not have a safety manager. The support plans to assign a patient safety manager or to activate the patient safety activities should be considered as policy challenges and research tasks with high priority.