Adverse Events following Discharge from the Hospital
Authors: Rodney A. Hayward, Timothy P. Hofer
Journal: Annals of Internal Medicine (2004)

Letters3 February 2004Adverse Events following Discharge from the HospitalRodney A. Hayward, MD and Timothy P. Hofer, MD, MScRodney A. Hayward, MDFrom Veterans Affairs Center for Practice Management and Outcomes Research, and University of Michigan Schools of Medicine and Public Health, Ann Arbor, MI 48113.Search for more papers by this author and Timothy P. Hofer, MD, MScFrom Veterans Affairs Center for Practice Management and Outcomes Research, and University of Michigan Schools of Medicine and Public Health, Ann Arbor, MI 48113.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-140-3-200402030-00021 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Forster and colleagues (1) reported that preventable adverse events frequently occur after hospital discharge. We do not doubt that this is true to an extent. However, the authors failed to account for serious problems with precision and accuracy in estimates of numbers of preventable adverse events obtained through implicit physician judgments (2-4). Using physician review to classify preventable events can result in substantial overestimates unless data are adjusted to account for the skew and poor reliability of reviewers' estimates of preventability (2-4). We are unsure why Forster and colleagues ignored this well-documented bias, but perhaps they thought ...References1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7. [PMID: 12558354] LinkGoogle Scholar2. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286:415-20. [PMID: 11466119] CrossrefMedlineGoogle Scholar3. Thomas EJ, Lipsitz SR, Studdert DM, Brennan TA. The reliability of medical record review for estimating adverse event rates. Ann Intern Med. 2002;136:812-6. [PMID: 12044129] LinkGoogle Scholar4. Hayward RA, Hofer TP. Clarifications & Response to Issues Raised in: “Estimating Hospital Deaths Due to Medical Errors: Preventability Is in the Eye of the Reviewer. Accessed at www.va.gov/annarbor-hsrd/hospdeaths.htm on 2 January 2004. Google Scholar5. Hofer TP, Bernstein SJ, DeMonner S, Hayward RA. Discussion between reviewers does not improve reliability of peer review of hospital quality. Med Care. 2000;38:152-61. [PMID: 10659689] CrossrefMedlineGoogle Scholar6. Shavelson RJ, Ruiz-Primo MA, Wiley EW. Notes on sources of sampling variability in science performance assessments. Journal of Educational Measurement. 1999;36:61-71. CrossrefGoogle Scholar Author, Article, and Disclosure InformationAuthors: Rodney A. Hayward, MD; Timothy P. Hofer, MD, MScAffiliations: From Veterans Affairs Center for Practice Management and Outcomes Research, and University of Michigan Schools of Medicine and Public Health, Ann Arbor, MI 48113. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Reliability of Medical Record Review for Estimating Adverse Event Rates Eric J. Thomas , Stuart R. Lipsitz , David M. Studdert , and Troyen A. Brennan The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital Alan J. Forster , Harvey J. Murff , Josh F. Peterson , Tejal K. Gandhi , and David W. Bates Adverse Events following Discharge from the Hospital Alan J. Forster and David W. Bates Adverse Events following Discharge from the Hospital Donald C. Rifas Adverse Events following Discharge from the Hospital Bruce Leff and Chad Boult Adverse Events following Discharge from the Hospital Matthew M. Medlock , Louis R. Cantilena Jr. , and Michael A. Riel Metrics 3 February 2004Volume 140, Issue 3Page: 232KeywordsAdverse eventsCognitive psychology ePublished: 3 February 2004 Issue Published: 3 February 2004 Copyright & PermissionsCopyright © 2004 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...