Zeroing In on Adverse Events in Hospitals

“Every week in the United States, up to 40 patients undergo a procedure meant for somebody else or the wrong body part.” Dr. Mark Chassin, president of the Joint Commission said in an interview National Journal last year. Sound shocking? According to a study published in Health Affairs, medical errors may be far more common than originally believed -- occurring in up to a third of all hospital inpatients.

Using The Global Trigger Tool – a methodology developed by the Institute for Healthcare Improvement – the study concludes that traditional hospital reporting systems failed to detect up to 90 percent of adverse events.

The findings were drawn using 2004 data from 800 randomly chosen patients admitted to three large, tertiary-care hospitals. Researchers compared adverse events using three separate methods: hospitals' voluntary reporting systems; the Agency for Healthcare Research and Quality's (AHRQ) Patient Safety Indicators; and the IHI’s Global Trigger Tool (GTT).

Using the GTT, the researchers identified 354 adverse events -- or up to 90 percent more adverse events than detected by other methods. The AHRQ's Patient Safety Indicators caught only 35 adverse events, or nine percent of the total, while voluntary reporting systems only detected four adverse events, or one percent of the total.

Currently, most hospitals gauge adverse events using voluntary reporting and the AHRQ’s Patient Safety Indicators.

Detecting adverse medical events is critical for patient safety, and most healthcare administrators rely on it to assess and prioritize areas to improve, as well as to develop modes for safer practice and treatment. Medical errors are also very expensive. The National Journal recently reported that "as much as 45 cents out of every dollar spent on US healthcare is related to a medical mistake.”

What do you think? Do sensitive assessment tools, such as the GTT methodology, help hospital administrators improve patient care and save costs?

Adventist Health System took the GTT methodology one step further. The Adverse Event Monitoring and Tracking Tool, compatible with IHI’s Global Trigger Tool Methodology, detects hidden adverse events or harms and automates the reporting process through database management and randomized reports. The tool enables hospitals to increase patient safety, reduce readmissions and length of stay by monitoring safety, influencing better practices, and improving reliability.