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Adverse Events in Hospitals Largely Undetected

Cheryl Clark, for HealthLeaders Media, April 7, 2011

Among less serious adverse events, for example, medication was required to reverse a problem the incident provoked, he explains. Among the most serious, intensive intervention was required to keep a patient from dying, or in the worst case, a patient actually died because of the adverse event.

According to the report, for the most severe errors, the IHI's GTT and the AHRQ systems each detected four adverse events that the voluntary system entirely missed. Among the least severe, the GTT caught 204 errors, AHRQ captured 23 but the hospital voluntary reporting system discovered none.

Currently, nearly all hospitals use these two adverse event detection systems that are far less extensive, specific or sensitive than the Global Trigger Tool, Classen says. They are:

• The voluntary system used by virtually all hospitals, when a nurse or other provider notices a problem, notifies someone about the incident, which provokes an investigation to determine whether the incident should be reported to authorities.

• The Agency for Healthcare Research and Quality's Patient Safety Indicators review, which encompasses more than the voluntary reporting system but less than the GTT. The AHRQ PSI looks only for certain codes in the medical records.

With the GTT, hospital employees such as nurses or pharmacists intensively review closed charts for codes, summaries, medications problems, lab results, operation reports or nursing notes to detect any clues that a mistake may have occurred. In this study, independent members of a team from the IHI, which contributed to the report, did the reviews.

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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.