ArticleJournal of the Royal Society of Medicine2001
Exploring the causes of adverse events in NHS hospital practice.
Article in Journal of the Royal Society of Medicine, 2001. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 62 papers, 8 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
62 citing papers in PubMed, 8 syntheses or guidelines pooled it.
- Optimizing ward rounds: systematic review and meta-analysis of interventions to enhance patient safety.The British journal of surgery · 2025Pooled it
- Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review.BMJ open · 2021Pooled it
- Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.BMJ (Clinical research ed.) · 2019Pooled it
- Frequency and Nature of Medication Errors and Adverse Drug Events in Mental Health Hospitals: a Systematic Review.Drug safety · 2017Pooled it
- Rapid response systems: a systematic review and meta-analysis.Critical care (London, England) · 2015Pooled it
- Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.BMJ quality & safety · 2012Pooled it
- The causes of and factors associated with prescribing errors in hospital inpatients: a systematic review.Drug safety · 2009Pooled it
- The incidence and nature of in-hospital adverse events: a systematic review.Quality & safety in health care · 2008Pooled it
- Comparing Patients' Opinions on the Hospital Discharge Process Collected With a Self-Reported Questionnaire Completed Via the Internet or Through a Telephone Survey: An Ancillary Study of the SENTIPAT Randomized Controlled Trial.Journal of medical Internet research · 2015Trial
- The use of a consultant-led ward round checklist to improve paediatric prescribing: an interrupted time series study.European journal of pediatrics · 2012Trial
- Exploring the Potential of Ambient AI for Inpatient Documentation: A Qualitative Study with Junior Doctors.Journal of medical systems · 2026Article
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- Assessment of postoperative complications and their risk factors in general surgery using clavien-dindo classification.Bioinformation · 2025Article
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- Impact of Simulation on the Development of Nursing Students' Competence in Adult Cardiopulmonary Resuscitation.Cureus · 2024Article
- Effect of the Ramathibodi Rapid Response System Triggered by the Ramathibodi Early Warning Score and Clinical Warning Signs on in-Hospital Mortality and the Incidence of Cardiopulmonary Resuscitation in Adult Hospitalized Patients.Therapeutics and clinical risk management · 2023Article
- Article
- Characteristics and outcomes of patients screened by rapid response team who transferred to the intensive care unit.BMC emergency medicine · 2022Article
- Generic analysis method to learn from serious adverse events in Dutch hospitals: a human factors perspective.BMJ open quality · 2022Article
- Validity and reliability of the Chinese version of the partners at care transitions measure.BMC health services research · 2021Article
2 more citing papers are in PubMed but not listed here.
Corrections and comments
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Authors and funding
3 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
In a previous paper we reported that 10.8% of patients admitted to two large hospitals in Greater London experienced one or more adverse events, of which half were deemed preventable. Here we examine the underlying causes of errors in clinical practice. Rather than identifying specific errors made by individuals, we have looked at possible faults in the organization of care. Adverse events were grouped according to stages in the care process: diagnosis, preoperative assessment and care, operative or invasive procedure (including anaesthesia), ward management, use of drugs and intravenous fluids and discharge from hospital. Less than 20% of preventable adverse events were directly related to surgical operations or invasive procedures and less than 10% to misdiagnoses. 53% of preventable adverse events occurred in general ward care (including initial assessment and the use of drugs and intravenous fluids) and 18% in care at the time of discharge. Probable contributory factors in these errors included dependence on diagnoses made by inexperienced clinicians, poor records, poor communication between professional carers, inadequate input by consultants into day-to-day care, and lack of detailed assessment of patients before discharge.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.