• Robert G Holloway, Deborah Tuttle, Tracy Baird, and W Keith Skelton.
• Office of Clinical Practice Evaluation, Strong Memorial Hospital, NY, USA. Robert_Holloway@urmc.rochester.edu
• Neurology. 2007 Feb 20;68(8):550-5.

ObjectivesTo analyze medical errors and adverse events occurring in stroke patients and to provide insights into system or stroke-specific processes that can be modified to reduce the likelihood of error and patient harm.MethodsWe analyzed spontaneously reported errors and adverse events reported within a voluntary and mandatory event reporting system in stroke patients admitted to a 750-bed academic medical center over a 3.5-year period between July 1, 2001, and December 31, 2004. We determined the frequency of near misses and preventable adverse events by event type (medication, adverse clinical, and falls). We performed a central event analysis to determine the most likely cause of preventable adverse events.ResultsOf the 1,440 stroke patients admitted during the study period, 173 patients (12.0%) experienced an adverse event that was reported within an event-reporting system. Of the 176 events in 148 patients reported in the voluntary event reporting system, 72 were falls, 62 were medication events, and 42 were adverse clinical events. Of the 28 events in 25 patients reported in the mandatory event-reporting system, all were adverse clinical events and involved patient harm. Of the total 201 unique events (3 events were reported in both systems), 18 were near misses and 183 were adverse events. Of the 183 adverse events, 86 were preventable, 37 were not preventable, and 60 were indeterminate. Preventable adverse events involved drugs and situations commonly seen in the stroke population and occurred in all aspects of care delivery from thrombolytic management to end-of-life care. Of the 86 preventable adverse events, 37% (32/86) were transcription/documentation errors, 23% (20/86) were failure to perform a clinical task, 10% (9/86) were communication/handoff errors between providers, and 10% (9/86) were failed independent checks/calculations.ConclusionsAdverse events and errors occur frequently in stroke patients. A disease-specific approach to analyzing spontaneously reported events may help close the feedback loop on patient safety and improve the quality of care.

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