Journal of

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Background: A variety of methods are available for identifying and measuring adverse events and medical errors in healthcare. The aim of this study is to review these methods with their strengths and weaknesses.

Methods: Electronic databases including Medline, Embase, Google Scholar and Iran Medex were searched to identify and summaries relevant studies.

Results: Different methods have been used to identify adverse events and their nature, causes and consequences. Record review seems to be the most common and the best method for measuring the rate and consequences of adverse events. However, this method is relatively expensive and time consuming and still underestimates the rate of adverse events. It is also not suitable for identifying the underlying causes of adverse events. The other method commonly used is reporting system including critical incident reporting system. This method is relatively cheap and more suitable for exploring the underlying causes of adverse events, but it is not suitable for identifying the rate of adverse events as it may underestimate many adverse events. Other methods include critical incident technique, interview, questionnaire, direct observation and review of claims and none of them are suitable for identifying the rate of adverse events but they might be useful for other purposes including assessment of the causes of adverse events.

Conclusion: Several methods can be used for study of adverse events. No single method can serve all purposes. Each method has some strengths and weaknesses. Using a combination of methods is more suitable, but this approach is more expensive and time consuming. Which combination of methods are more appropriate, depends on several factors including the aim of the study and resources available.

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Background: Medical errors and adverse events are the main reasons of many avoidable deaths and imposed expenditures in worldwide health systems. Hence, this study aimed to recognize some challenges, medical errors and adverse events, and to address the appropriate solutions in order to solve them in the Iranian health system.

Materials and Methods: This qualitative study had three main data resources including key informants, national documents and expert panel. Key informants (30 persons) and experts (12 persons) were selected purposefully from macro, meso and micro levels of health system and some other health related organizations. Data were interpreted and analyzed through a mixed (inductive/deductive) thematic framework.

Results: Although, most reasons of medical errors were in relation with weak patient security system and low level security culture in hospitals, other factors like manpower, physical and external agents of hospital environment induced these errors as well. The most considerable solutions to decrease the medical errors comprised identification of medical error reasons in different levels of heath system, errors documentation and generation a consolidated system for recognition and following the errors and their main causes.

Conclusion: Relieveing the reasons of medical errors and adverse events can be a great step to prevent them. In order to eliminate the medical errors and its challenges, it is necessary to develop the consonant programs in national level via conclusive will of organizations, groups and related individuals.

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Background: Medical errors represent a serious problem for intensive care and increase the length of stay and mortality. Tracking of medical errors in hospital have focused on voluntary reporting of errors, but 10 to 20 % of errors are ever reported and, of those, 90-95 percent cause no harm to patients. This study was conducted to recognition and analysis medical errors in Intensive Care Unit by GTT in 2019.   
Materials & Methods: This study was a retrospective descriptive-experimental and was conducted in the Intensive Care Unit of a public hospital in Tehran. In 2019 for 13 weeks,127 records were separately reviewed by two nurses by using the IHI checklist and final confirmation was performed by the physician. The data were analyzed by SPSS 22 software.
 Results. 622 triggers, 277 adverse events related to triggers, 121 adverse events without trigger and totally 398 adverse events were identified in ICU. 93 records from 127 records had adverse events. The incidence rate of adverse events was 73/2%, 3/13 adverse events per pa­tient and the incidence rate was 24/8 adverse events per 100 patients-day. The most frequency of events and harms were respectively related to care, intensive care, surgery and medication modules.
Conclusion. According to the result of patient records reviewing and the high rate of AEs that required intervention and also the result of similar study, we can state this tool is more reliable than other methods to detect AEs, such as voluntary reporting of error.