A new piece featured in Health Affairs online magazine has uncovered the fact that in more than a decade of national focus on patient safety, medical errors and other adverse events have occurred as much as ten times more than some previous estimates have recorded, costing the nation billions.

Editor-in-Chief Susan Dentzer says:

“Without doubt, we’ve seen improvements in health care over the past decade, and even pockets of excellence, but overall progress has been agonizingly slow. It’s clear that we still have a great deal of work to do in order to achieve a health care system that is consistently high-quality; that is, safe, effective, patient-centered, efficient, timely, and devoid of disparities based on race or ethnicity.”

Agency for Healthcare Research and Quality (AHRQ) indicators and voluntary reporting missed more than 90% of adverse events identified by the Global Trigger Tool, and researchers say this may be a low ball assumption.

The use of “triggers,” or clues, to identify adverse events (AEs) is an effective method for measuring the overall level of harm in a health care organization. The IHI Global Trigger Tool for Measuring AEs provides instructions for training reviewers in this methodology and conducting a retrospective review of patient records using triggers to identify possible AEs.

This tool provides an easy-to-use method for accurately identifying AEs (harm) and measuring the rate of AEs over time. Tracking AEs over time is a useful way to tell if changes being made are improving the safety of the care processes. Many hospitals have used this tool to identify AEs, to measure the level of harm from each AE, and to identify areas for improvement in their organizations.

The magazine says that:

“Although the Global Trigger Tool is a somewhat more resource-intensive method because it involves medical record review…it could be incorporated into commercial electronic health record systems, thus making it easier and less costly to use.”

The AHRQ’s mission statement is as follows:

“The Agency for Healthcare Research and Quality’s (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. As 1 of 12 agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research.”

So which tracking tool is best?

The bottom line is that the Institute for Healthcare Improvement’s Global Trigger Tool found at least ten times more confirmed, serious events than other tracking 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.

Another great online tool is HCUPnet. It is an online query system that gives you instant access to the largest set of all-payer health care databases that are publicly available. Using HCUPnet’s easy step-by-step query system, you can generate tables and graphs on national and regional statistics and trends for community hospitals in the U.S. In addition, community hospital data are available for those States that have agreed to participate in HCUPnet.

Sources: Health Affairs, The Agency For Healthcare Research and Quality and The Insitiute for Healthcare Improvement

Written by Sy Kraft