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Adverse Events in Hospitals Largely Undetected

Cheryl Clark, for HealthLeaders Media, April 7, 2011

"A trigger could be a notation indicating, for example, a medication stop order, an abnormal lab result, or use of an antidote medication," the authors wrote. An investigation would ensue.

Classen says that only about 2% of the hospitals in the country now use the GTT. That's because the method is time consuming, labor-intensive, and expensive, especially in the absence of well-developed electronic medical record systems, which the hospitals in this study all had, he says.

Classen explains that the AHRQ method fails in part because hospital staff who insert codes "are not necessarily highly trained clinical individuals," so if the adverse event is not well documented in the medical record, the AHRQ system can't find it. "If it's not obvious and apparent, they won't see it and even if it is, they may miss it," he says.

As an example, he explains, "if a patient has a side effect from a drug that requires an antidote to be ordered, the AHRQ system would miss it, but under the GTT, our reviewers would have picked it up."

Classen says the study findings did not surprise him "because I do work in hospitals all the time, and I see the use of these other approaches – which are much cheaper and easier to do – often seem to miss these problems."


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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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.