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Hospital Error Numbers

By April 13, 2011Commentary

Patient safety, particularly in institutions, is obviously a vital concern.  Policymakers and hospital managers have developed several methods of identifying treatment errors and programs to discourage the occurrence of such errors, including, for example, the CMS “never events” policy.  An article in Health Affairs suggests that most current methods of identifying safety issues may do a poor job.   (Health Affairs Article) The traditional methods of looking at patient errors is through gross measures, like mortality, or by sentinel event monitoring.  Voluntary reporting systems are often used or review of administrative diagnosis and reimbursement codes.

The Agency for Healthcare Research and Quality has created a Patient Safety Indicators index that is also used to quantify treatment errors.  A newer tool is called the Global Trigger Tool, which involves a detailed chart review by several health professionals.  As might be imagined, this is an expensive process.  The study compared the AHRQ method, the Global Trigger Tool and hospitals’ voluntary reporting systems in three large tertiary care hospitals, all of which had sophisticated patient safety departments and had received awards for their efforts.  The review covered almost 800 randomly selected patients.

The Global Trigger method found 354 patient safety issues, most of which were of the lowest severity, not that any errors should be tolerated.  AHRQ’s index found only 35 and the voluntary reporting systems 4.  This would suggest that the most widely used systems are substantially under-reporting quality issues.  As would be expected, older and more ill patients are more likely to be subjected to a safety problem.  Medication, surgery and procedures were the most common source of errors.  If the study is accurate, there is a long, long way to go to ensure that patient treatment errors are avoided and most current quality improvement programs must not be doing the job.

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