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June 26, 1991, Vol 265, No. 24 >
ARTICLE | June 26, 1991

Hospital Characteristics Associated With Adverse Events and Substandard Care FREE

Troyen A. Brennan, MD, JD, MPH; Liesi E. Hebert, ScD; Nan M. Laird, PhD; Ann Lawthers, ScD; Kenneth E. Thorpe, PhD; Lucian L. Leape, MD; A. Russell Localio, MS, JD; Stuart R. Lipsitz, ScD; Joseph P. Newhouse, PhD; Paul C. Weiler, LLB; Howard H. Hiatt, MD
[+] Author Affiliations

Reprint requests to Division of General Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (Dr Brennan).


JAMA. 1991;265(24):3265-3269. doi:10.1001/jama.1991.03460240061028
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References

To explore the epidemiology of adverse events (AEs), which were defined as injuries due to medical treatment, and that subset of AEs caused by negligence, we studied interhospital variation in these outcomes in a sample of 31 000 medical records drawn from a random selection of 51 hospitals in New York in 1984. We found a substantial variation in both AE rates (0.2% to 7.9%; mean, 3.2%) and the percentage of AEs due to negligence (1% to 60%; mean, 24.9%) among hospitals. Univariate analyses of AEs revealed that primary teaching institutions had significantly higher rates (4.1%) and rural hospitals had significantly lower ones (1.0%). The percentage of AEs due to negligence was lower in primary teaching (10.7%) and for-profit (9.5%) hospitals and was significantly higher in hospitals with predominantly (>80%) minority patients who had been discharged (37%). These findings were corroborated by multivariate analysis. Our results suggest that AEs and negligence are not randomly distributed and that certain types of hospitals have significantly higher rates of injuries due to substandard care. These observations may represent an important improvement on existing measures of quality because they take into account the fact that some hospitals' populations may be at risk of suffering a poor outcome.

(JAMA. 1991;265:3265-3269)

REFERENCES

1 +
Hiatt HH, Barnes BA, Brennan TA, et al.  A study of medical injury and medical malpractice: an overview . N Engl J Med. 1989;;321:480-484.
2 +
Brennan TA, Leape LL, Laird NM.  Incidence of adverse events and negligent care in hospitalized patients: Medical Practice Study I . N Engl J Med. 1991;;324:370-376.
3 +
New York State Department of Health. Statwide Planning and Research Cooperative System: Annual Report Series, 1984 . Albany: New York State Dept of Health; 1985;.
4 +
Shah BV, LaVange LM, Barnwell BG, et al. SESUDAAN: Standard Errors Program for Computing of Standardized Rates From Sample Survey Data . Research Triangle Park, NC: Research Triangle Institute; 1981;.
5 +
Shah BV, Folsom RE, Harrell FE, Dillard CN. RTI LOGIT: Procedure for Logistic Regression on Survey Data . Research Triangle Park, NC: Research Triangle Institute; 1984;.
6 +
Donabedian A.  The epidemiology of quality . Inquiry . 1985;;22:282-292.
7 +
Jost TS.  Administrative law issues involving the Medicare utilization and quality control peer review organization (PRO) program . Ohio State Law J. 1989;;50:1-4.
8 +
Clearly PD, McNeil BJ.  Patient satisfaction as an indicator of quality care . Inquiry . 1988;;25:25-36.
9 +
Palmer RH. Ambulatory Health Care Evaluation: Principles in Practice . Chicago, Ill: American Hospital Publishing Inc; 1983;.
10 +
Laffel G, Blumenthal D.  The case for using industrial quality management science in health care organizations . JAMA . 1989;;262:2869-2873.
11 +
Bigby J, Dunn J, Goldman L, et al.  Assessing the preventability of emergency hospital admission . Am J Med. 1986;;83:1031-1037.
12 +
Mason WB, Bedwell CL, Vander-Zwaag R, Runyan JW.  Why people are hospitalized: a description of preventable factors leading to admission for medical illness . Med Care. 1980;;18:147-153.
13 +
Safran C, Phillips RS.  Interventions to prevent readmission: the constraints of cost and efficacy . Med Care . 1989;;27:204-211.
14 +
Greenfield S, Aronow HU, Elashoff RM, Watanabe D.  Flaws in mortality data: the hazards of ignoring comorbid disease . JAMA . 1988;;260:2253-2255.
15 +
Jencks SF, Williams DK, Kay TL.  Assessing hospital-associated death from discharge data: the role of length of stay and comorbidities . JAMA . 1988;;260:2240-2246.
16 +
Dubois RW, Brook RH.  Preventable deaths: who, how often, and why? Ann Intern Med. 1988;;109:582-589.
17 +
Feigenson JS, Feigenson WD, Gitlow S, et al.  Outcome and cost for stroke patients in academic and community hospitals: a comparison of two groups referred to a regional rehabilitation center . JAMA . 1978;;240:1878-1880.
18 +
Morehead MA. A Study of Hospital Care Secured by a Sample of Teamster Family Members in New York City . New York, NY: Columbia School of Public Health and Administrative Medicine; 1964;.
19 +
Shortell SM, Lofergo JP.  Hospital medical staff organization and quality of care: results for myocardial infarction and appendectomy . Med Care. 1981;;19:1041.
20 +
Dubois RW, Brook RH, Rogers WH.  Adjusted hospital death rates: a potential screen for quality of medical care . Am J Public Health. 1987;;77:1162-1166.
21 +
Hartz AJ, Krakauer H, Huhn EM, et al.  Hospital characteristics and mortality rates . N Engl J Med. 1989;;321:1720-1725.
22 +
Fink A, Yano EM, Brook RH.  The condition of the literature on differences in hospital mortality . Med Care. 1989;;27:315-316.
23 +
Green J, Wintfeld N, Sharkey P, Passman LJ.  The importance of severity of illness in assessing hospital mortality . JAMA . 1990;;263:241-246.
24 +
Park RE, Brook RH, Kosecoff J, et al.  Explaining variations in hospital death rates: randomness, severity of illness, and quality of care . JAMA . 1990;;264:484-490.
25 +
Berwick DM, Wald DL.  Hospital leaders' opinions of the HCFA mortality data . JAMA . 1990;;263:247-249
26 +
Brennan TA, Localio AR, Laird NM.  Reliability and validity of judgements concerning adverse events and negligent care suffered by hospitalized patients . Med Care. 1989;;29:505-510.
27 +
Kahn KL, Rubenstein LV, Draper D, et al.  The effects of the DRG-based prospective payment system on quality of care for hospitalized patients: an introduction to the series . JAMA . 1990;;264:1953-1955.
28 +
Leape LL, Brennan TA, Laird NM, et al.  The nature of adverse events in hospitalized patients: results from the Medical Practice Study II . N Engl J Med. 1991;;324:377-383.
29 +
Steel K, Gertman PM, Crescenzi C, Anderson J.  Iatrogenic illness on a general medical service at a university hospital . N Engl J Med. 1981;;304:638-642.
30 +
Couch NP, Tilney NL, Rayner AA, Moore FD.  The high cost of low-frequency events: the anatomy and economics of surgical mishaps . N Engl J Med. 1981;;304:634-637.
31 +
Lakshmanan MC, Hershey CO, Breslau D.  Hospital admissions caused by iatrogenic disease . Arch Intern Med. 1986;;146:1931-1934.
32 +
Abramson NS, Wald KS, Grennik AN, Robinson D, Snyder JV.  Adverse occurrences in intensive care units . JAMA . 1980;;244:582-584.
33 +
California Medical Association. Medical Insurance Feasibility Study . Sacramento, Calif: Sutter; 1975;.
34 +
Wenneker M, Epstein AM.  Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts . JAMA . 1989;;261: 253-257.
35 +
Yergan J, Flood A, Logerfo J, Diehr P.  Relationship between patient race and the intensity of hospital services . Med Care. 1987;;25:592-600.
36 +
Burstin HR, Lipsitz SR, Brennan TA.  Socioeconomic status and risk for negligent injury in hospitals . Clin Res. 1991;;39:189A.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

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1 +
Hiatt HH, Barnes BA, Brennan TA, et al.  A study of medical injury and medical malpractice: an overview . N Engl J Med. 1989;;321:480-484.
2 +
Brennan TA, Leape LL, Laird NM.  Incidence of adverse events and negligent care in hospitalized patients: Medical Practice Study I . N Engl J Med. 1991;;324:370-376.
3 +
New York State Department of Health. Statwide Planning and Research Cooperative System: Annual Report Series, 1984 . Albany: New York State Dept of Health; 1985;.
4 +
Shah BV, LaVange LM, Barnwell BG, et al. SESUDAAN: Standard Errors Program for Computing of Standardized Rates From Sample Survey Data . Research Triangle Park, NC: Research Triangle Institute; 1981;.
5 +
Shah BV, Folsom RE, Harrell FE, Dillard CN. RTI LOGIT: Procedure for Logistic Regression on Survey Data . Research Triangle Park, NC: Research Triangle Institute; 1984;.
6 +
Donabedian A.  The epidemiology of quality . Inquiry . 1985;;22:282-292.
7 +
Jost TS.  Administrative law issues involving the Medicare utilization and quality control peer review organization (PRO) program . Ohio State Law J. 1989;;50:1-4.
8 +
Clearly PD, McNeil BJ.  Patient satisfaction as an indicator of quality care . Inquiry . 1988;;25:25-36.
9 +
Palmer RH. Ambulatory Health Care Evaluation: Principles in Practice . Chicago, Ill: American Hospital Publishing Inc; 1983;.
10 +
Laffel G, Blumenthal D.  The case for using industrial quality management science in health care organizations . JAMA . 1989;;262:2869-2873.
11 +
Bigby J, Dunn J, Goldman L, et al.  Assessing the preventability of emergency hospital admission . Am J Med. 1986;;83:1031-1037.
12 +
Mason WB, Bedwell CL, Vander-Zwaag R, Runyan JW.  Why people are hospitalized: a description of preventable factors leading to admission for medical illness . Med Care. 1980;;18:147-153.
13 +
Safran C, Phillips RS.  Interventions to prevent readmission: the constraints of cost and efficacy . Med Care . 1989;;27:204-211.
14 +
Greenfield S, Aronow HU, Elashoff RM, Watanabe D.  Flaws in mortality data: the hazards of ignoring comorbid disease . JAMA . 1988;;260:2253-2255.
15 +
Jencks SF, Williams DK, Kay TL.  Assessing hospital-associated death from discharge data: the role of length of stay and comorbidities . JAMA . 1988;;260:2240-2246.
16 +
Dubois RW, Brook RH.  Preventable deaths: who, how often, and why? Ann Intern Med. 1988;;109:582-589.
17 +
Feigenson JS, Feigenson WD, Gitlow S, et al.  Outcome and cost for stroke patients in academic and community hospitals: a comparison of two groups referred to a regional rehabilitation center . JAMA . 1978;;240:1878-1880.
18 +
Morehead MA. A Study of Hospital Care Secured by a Sample of Teamster Family Members in New York City . New York, NY: Columbia School of Public Health and Administrative Medicine; 1964;.
19 +
Shortell SM, Lofergo JP.  Hospital medical staff organization and quality of care: results for myocardial infarction and appendectomy . Med Care. 1981;;19:1041.
20 +
Dubois RW, Brook RH, Rogers WH.  Adjusted hospital death rates: a potential screen for quality of medical care . Am J Public Health. 1987;;77:1162-1166.
21 +
Hartz AJ, Krakauer H, Huhn EM, et al.  Hospital characteristics and mortality rates . N Engl J Med. 1989;;321:1720-1725.
22 +
Fink A, Yano EM, Brook RH.  The condition of the literature on differences in hospital mortality . Med Care. 1989;;27:315-316.
23 +
Green J, Wintfeld N, Sharkey P, Passman LJ.  The importance of severity of illness in assessing hospital mortality . JAMA . 1990;;263:241-246.
24 +
Park RE, Brook RH, Kosecoff J, et al.  Explaining variations in hospital death rates: randomness, severity of illness, and quality of care . JAMA . 1990;;264:484-490.
25 +
Berwick DM, Wald DL.  Hospital leaders' opinions of the HCFA mortality data . JAMA . 1990;;263:247-249
26 +
Brennan TA, Localio AR, Laird NM.  Reliability and validity of judgements concerning adverse events and negligent care suffered by hospitalized patients . Med Care. 1989;;29:505-510.
27 +
Kahn KL, Rubenstein LV, Draper D, et al.  The effects of the DRG-based prospective payment system on quality of care for hospitalized patients: an introduction to the series . JAMA . 1990;;264:1953-1955.
28 +
Leape LL, Brennan TA, Laird NM, et al.  The nature of adverse events in hospitalized patients: results from the Medical Practice Study II . N Engl J Med. 1991;;324:377-383.
29 +
Steel K, Gertman PM, Crescenzi C, Anderson J.  Iatrogenic illness on a general medical service at a university hospital . N Engl J Med. 1981;;304:638-642.
30 +
Couch NP, Tilney NL, Rayner AA, Moore FD.  The high cost of low-frequency events: the anatomy and economics of surgical mishaps . N Engl J Med. 1981;;304:634-637.
31 +
Lakshmanan MC, Hershey CO, Breslau D.  Hospital admissions caused by iatrogenic disease . Arch Intern Med. 1986;;146:1931-1934.
32 +
Abramson NS, Wald KS, Grennik AN, Robinson D, Snyder JV.  Adverse occurrences in intensive care units . JAMA . 1980;;244:582-584.
33 +
California Medical Association. Medical Insurance Feasibility Study . Sacramento, Calif: Sutter; 1975;.
34 +
Wenneker M, Epstein AM.  Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts . JAMA . 1989;;261: 253-257.
35 +
Yergan J, Flood A, Logerfo J, Diehr P.  Relationship between patient race and the intensity of hospital services . Med Care. 1987;;25:592-600.
36 +
Burstin HR, Lipsitz SR, Brennan TA.  Socioeconomic status and risk for negligent injury in hospitals . Clin Res. 1991;;39:189A.

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