Adverse event reporting

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Interesting research on how poorly hospitals are reporting adverse events. Lindekugel, DCPortland OR. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured.Classen DC, Resar R, F, Federico F, el T, Kimmel N, Whittington JC, el A, Seger A, BC.SourceUniversity of Utah, Salt Lake City, Utah, USA. dclassen@...Erratum inHealth Aff (Millwood). 2011 Jun;30(6):1217. AbstractIdentification

and measurement of adverse medical events is central to patient safety,

forming a foundation for accountability, prioritizing problems to work on, generating ideas for safer care, and testing which interventions work. We compared three methods to detect adverse events in hospitalized

patients, using the same patient sample set from three leading hospitals. We found that the adverse event detection methods commonly used to track patient safety in the United States today-voluntary reporting and the Agency for Healthcare Research and Quality's Patient Safety Indicators-fared very poorly compared to other methods and missed

90 percent of the adverse events. The Institute for Healthcare Improvement's Global Trigger Tool found at least ten times more confirmed, serious events than these other methods. Overall, adverse events occurred in one-third of hospital admissions. Reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US health

care system and misdirect efforts to improve patient safety.Comment inHealth Aff (Millwood). 2011 Jul;30(7):1391.