SDW news brief: One in three hospitalized patients suffers an adverse event

Staff Development Weekly: Insight on Evidence-Based Practice in Education, April 15, 2011

Just when you thought you and your fellow providers have made hospitals safer, the April edition of the journal Health Affairs publishes a series of reports that might change your mind.

At least a dozen separate reports in the quality-themed issue focus on how bad the system still is, and how much it needs to improve. Worse, as at least one study emphasizes, healthcare providers in large part are unaware how many harmful errors they still make.

In one report, researchers who studied three methods to detect serious adverse events conclude that the commonly used method of voluntary reporting and the Agency for Healthcare Research and Quality's Patient Safety Indicators capture only one-tenth of these flaws in care.

On the other hand, a newer tool developed by the Institute for Healthcare Improvement, called the Global Trigger Tool, now used by only 2% of hospitals in the U.S., caught all 10.

Specifically, the GTT detected 354 adverse events, while the AHRQ system, used by roughly half the hospitals in the U.S., found only 35 and the voluntary method found just four, according to the authors. These adverse events include medication errors, procedural errors and hospital-acquired infections, pulmonary venous thromboembolisms, pressure ulcers, device failures and patient falls.

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Source: HealthLeaders Media

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