Adverse Events in Hospitals Largely Undetected
"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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