Abstract
Nation-wide trends of fatal adverse events which caused patient's deaths or severe disabilities and numbers of in-hospital reports concerning adverse events or near misses have not been determined sufficiently. This study aimed to determine the progression of hospitals that have experienced fatal adverse events, progression of number of reported adverse events or near misses, and relationships between those progressions and the improvements of hospital system such as the assignment of patient safety managers, hospital accreditation or other factors of relevance.
Mail surveys were conducted on all member hospitals of All Japan Hospital Association in 2004, 2011, 2014 and 2015. The questionnaires included questions about the characteristics of hospitals, the experience of fatal adverse events in the immediate last three years and the annual number of reported adverse events or near misses. The progression of data from 2011 to 2015 was analyzed, and the data in 2004 is shown here as reference.
Recovery rates of each year ranged from 18% to 28%. From 2011 to 2015, the hospitals which experienced fatal adverse events were increased (23%, 29%, p=0.02), and the median number of in-hospital reports per bed tended to increase (2.7 cases, 3.3 cases). The hospital accreditation and the assignment of full-time patient safety manager were associated with the increase. When calibrated to the function of hospitals, the size of hospitals, the hospital accreditation status and the assignment of patient safety managers, we found the year of survey was correlated not with the experience of fatal adverse events but with the number of in-hospital reports.
The increase in hospitals that experienced fatal adverse events may be the result of improved detection capability for fatal adverse events by improving hospital system. The increase in number of reports may be the result of improvements in hospital system and other activities that were not grasped in our study.
