Exploring the causes of adverse events in hospitals and potential prevention strategies

Objectives To examine the causes of adverse events (AEs) and potential prevention strategies to minimise the occurrence of AEs in hospitalised patients. Methods For the 744 AEs identified in the patient record review study in 21 Dutch hospitals, trained reviewers were asked to select all causal factors that contributed to the AE. The results were analysed together with data on preventability and consequences of AEs. In addition, the reviewers selected one or more prevention strategies for each preventable AE. The recommended prevention strategies were analysed together with four general causal categories: technical, human, organisational and patient-related factors. Results Human causes were predominantly involved in the causation of AEs (in 61% of the AEs), 61% of those being preventable and 13% leading to permanent disability. In 39% of the AEs, patient-related factors were involved, in 14% organisational factors and in 4% technical factors. Organisational causes contributed relatively often to preventable AEs (93%) and AEs resulting in permanent disability (20%). Recommended strategies to prevent AEs were quality assurance/peer review, evaluation of safety behaviour, training and procedures. For the AEs with human and patient-related causes, reviewers predominantly recommended quality assurance/peer review. AEs caused by organisational factors were considered preventable by improving procedures. Discussion Healthcare interventions directed at human causes are recommended because these play a large role in AE causation. In addition, it seems worthwhile to direct interventions on organisational causes because the AEs they cause are nearly always believed to be preventable. Organisational factors are thus relatively easy to tackle. Future research designs should allow researchers to interview healthcare providers that were involved in the event, as an additional source of information on contributing factors.

Implementing a Social Norms Approach to Reduce Alcohol Abuse on Campus: Lessons learned in the shadow of The World\u27s Largest Six-Pack

Many institutions of higher education are struggling with the problem of excessive alcohol consumption by students. Colleges and universities want to be ‘good neighbors’ in their communities and must limit legal and social risks that result from excessive alcohol consumption by students. At the same time, colleges and universities operate in an increasingly challenging marketplace where many prospective students seek out institutions with a ‘party school’ reputation. Thus, higher education institutions are finding it difficult to define and carry out alcohol reduction measures that satisfy all constituents. This article discusses the approach taken at the University of Wisconsin—La Crosse. UW-L is an institution that identified a serious alcohol consumption problem and had to address the problem in a community where high levels of alcohol consumption are socially and culturally condoned. The article profiles the UW-L community and discusses the campaign model and strategy chosen. Quantitative and qualitative measures of success are discussed, along with lingering issues of resistance. The article ends with a summary of current issues and future directions being taken by the campaign

Exclusive electromagnetic production of strangeness on the nucleon : review of recent data in a Regge approach

In view of the numerous experimental results recently released, we provide in this letter an update on the performance of our simple Regge model for strangeness electroproduction on the nucleon. Without refitting any parameters, a decent description of all measured observables and channels is achieved. We also give predictions for spin transfer observables, recently measured at Jefferson Lab which have high sensitivity to discriminate between different theoretical approaches.Comment: 5 pages, 5 figure