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From the Office of Clinical Practice Evaluation (R.G.H., D.T., T.B., W.K.S.), Strong Memorial Hospital, and Departments of Neurology (R.G.H.) and Community and Preventive Medicine (R.G.H., D.T.), University of Rochester School of Medicine and Dentistry, NY.
Address correspondence and reprint requests to Dr Holloway, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave., Box 673, Rochester, NY 14620; e-mail: Robert_Holloway{at}urmc.rochester.edu
Objectives: To 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.
Methods: We 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.
Results: Of 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.
Conclusions: Adverse 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.
Editorial, see page 542
Partially supported by a grant from MCIC Vermont, Inc.
Disclosure: The authors report no conflicts of interest.
Received May 15, 2006. Accepted in final form November 2, 2006.
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  Errors in Acute-Stroke Care Journal Watch Emergency Medicine, March 30, 2007; 2007(330): 4 - 4. [Full Text]
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 M. Rizzo and T. H. Glick Medical errors after stroke: Preventable or inevitable? Neurology, February 20, 2007; 68(8): 542 - 543. [Full Text] [PDF]
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