A patient safety incident (PSI) is an event or circumstance which could have resulted, or
did result, in unnecessary harm to a patient. The term encompasses the more frequently
used terms medical error and system failure, and is now preferred. PSIs are a common
cause of morbidity and mortality in a variety of health care settings.
Some situations, as complex or urgent care, carry a greater risk, but significant errors
may occur in any setting.
All studies identified in this review were conducted in high-income countries.
PSIs were common in all the settings evaluated, ranging from 10% to 63%. All
studies were conducted in high-income countries.
Eight interventions to reduce prescription errors are probably effective in reducing
some form of PSIs, but it is not known if they reduce serious errors or mortality
(computerized reminders, multidisciplinary approach, patient-oriented leaflets,
automated bedside dispensing, syringe marked with doses, self-medication program,
illumination in the workplace, pharmacist participation in rounds).
Four interventions evaluated to reduce diagnostic errors may not lead to any difference
(utilization of protocol by triage nurse, teaching acute illness observation
scales to mothers, pain relief for abdominal pain needing possible surgical resolution,
nurse practitioner vs. junior doctor providing care).
Two interventions evaluated probably decrease management errors (computerized
reminders, multidisciplinary approach).