ADVERSE EVENTS IN PRIMARY-CARE IDENTIFIED FROM A RISK-MANAGEMENT DATABASE

BACKGROUND. The inevitability of adverse events in medicine arises fro m human fallibility, negligent care, limits of medical knowledge, risk s inherent in medical practice, and biological variability among indiv iduals. A better understanding of the nature and causes of adverse eve nts is necessary to reduce their occurrence and limit their harm. This study describes adverse events identified from a risk-management data base that occurred in an outpatient primary care setting. METHODS. Inc ident reports filed with the risk-management office of an academic med ical center between January 1, 1991, and June 30, 1996, by eight prima ry health care clinics affiliated with the center were eligible for th e study, Two independent reviewers assessed the incidents to determine whether there were adverse medical events, Incidents classified as ad verse events were analyzed to determine the cause, potential preventab ility, and outcome RESULTS. The prevalence of adverse events was 3.7 p er 100,000 clinic visits over a period of 5 1/2 years, Twenty-nine of 35 (83%) adverse events were due to medical errors and were considered preventable. The causes of the adverse events included 9 diagnostic e rrors (26%), 11 treatment errors (31%), and 9 other errors (26%). Of t he adverse events attributed to medical errors, 4 (14%) resulted in a permanent, disabling injury and 1 (3%) resulted in a death. CONCLUSION S. Serious adverse events appear to occur infrequently in primary care outpatient practice, although these data probably underestimate the o verall prevalence. To reduce or prevent the occurrence of adverse even ts in primary care, better systems for recognizing and tracking them a nd for assessing their causes are needed.