Diagnostic Adverse Events Usually Due to Human Failure

Associated with higher mortality rate than other types of adverse events

TUESDAY, June 29 (HealthDay News) -- Diagnostic adverse events (DAEs) are most often caused by human error, and their consequences are more severe than those of other types of adverse events, according to research published in the June 28 issue of the Archives of Internal Medicine.

Laura Zwaan, of the VU University Medical Center in Amsterdam, Netherlands, and colleagues reviewed 7,926 randomly selected patient records from 21 hospitals across the Netherlands. Using the Harvard Medical Practice Study protocol, the authors identified and analyzed all DAEs and compared them to other types of adverse events.

The researchers identified DAEs in 0.4 percent of hospital admissions, which accounted for 6.4 percent of all adverse events. The researches categorized 83.3 percent of the DAEs as preventable, with the leading cause identified as human error (96.3 percent). Organization-related factors also were identified in 25 percent of errors, and patient-related factors were identified in 30.0 percent. The researchers determined that the consequences of DAEs were more severe (i.e., greater mortality rate) than the consequences of other types of adverse events.

"DAEs represent an important error type, and the consequences of DAEs are severe. The causes of DAEs were mostly human, with the main causes being knowledge-based mistakes and information transfer problems. Prevention strategies should focus on training physicians and on the organization of knowledge and information transfer," the authors write.

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Jeff Muise

Jeff Muise

Updated on June 29, 2010

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