Adverse Events in Hospitals Largely Undetected
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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