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Adverse Events in Hospitals Largely Undetected

Cheryl Clark, for HealthLeaders Media, April 7, 2011

Adverse events serious enough to harm patients are occurring in U.S. hospitals at least ten times more often than previously measured, according to a report released Thursday in the journal Health Affairs.

Researchers went to three large hospitals in the U.S., all of which have well established patient safety detection systems already in place.

The study team then tested a newer, more expensive, and extensive event system called the Institute for Healthcare Improvement's "Global Trigger Tool," against two more common but less sensitive tools. Those two are the voluntary reporting method and the Agency for Healthcare Research and Quality's Patient Safety Indicator method.

The GTT detected 354 adverse events, while the AHRQ system found 35 and the voluntary method found only four.

All errors discovered were serious enough to require some intervention, says lead author of the report, David Classen, associate professor of medicine at the University of Utah in Salt Lake City.

"The point of all this is that we need to develop better tools to measure the safety of care that we deliver," he said. Classen adds that many hospitals think they're capturing the essence of medical errors, but in fact there's a lot more they need to know about pitfalls in the process of care. "It's a learning curve that a lot of places have to go through," he says.

In this study, the GTT did not distinguish between preventable and unavoidable errors, but Classen says that other studies suggest that errors between 40% and 60% of the adverse events captured by these tools are considered preventable.

The GTT caught many types of adverse events, from those considered extremely serious and lethal, to those that could be quickly averted. They include infections, venous thromboembolisms, pressure ulcers, device failures and falls.

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2 comments on "Adverse Events in Hospitals Largely Undetected"


Todd Madden (4/22/2011 at 5:04 PM)
I think the study speaks volumes of the poor care provided on average at US hospitals. I would never have surgery at a US petri dish, err hospital. There is much better care and technology used at non US facilities like Severance and Bumrungrad where CPOE is regularly used and they can actual manage look alike and sound alike drugs. Todd

Cary Gutbezahl, MD (4/7/2011 at 2:50 PM)
This fascinating study is worthy of reporting but the overinterpretation of its findings are inappropriate. Like most studies, this study has limitations, which limit the interpretation of its findings. The study was undertaken at three large hospitals. Under what logic are three large hospitals representative of the entire health system? Are the finding at large hospitals the same as small hospitals? Large hospitals often have different care models and are referral facilities. Also, how can three hospitals be considered representative of all large hospitals. Three is a pretty small sample size relative to the universe of comparable hospitals. There is no doubt that the findings are worthy of concern, but they should not be misinterpreted as universal without corroborating evidence. Scientific principles need to be followed, not just in the design of studies but in their interpretation.