Health Affairs Reports New Study That Majority of Medical Errors Not Reported

The April issue of Health Affairs features a number of articles addressing patient safety and the quality of healthcare. One of the articles presents the results of a new study that reports that medical errors and adverse events are significantly under-reported at hospitals. They report that these events occur in one-third of hospital admissions which would be as much as ten times more than some previous estimates have indicated, The April issue is funded by the Robert Wood Johnson Foundation.

As reported in Health Affairs- by Chris Fleming



...The patient safety study, conducted by David Classen of the University of Utah and coauthors at the Institute for Healthcare Improvement, compared three methods for detecting adverse events in hospitalized patients, including the Institute’s own Global Trigger Tool. The study drew on comparable samples of patients from three leading hospitals that had undertaken quality and safety improvement efforts.

Among the 795 patient records reviewed, voluntary reporting detected four events, the Agency for Healthcare Research and Quality (AHRQ) Indicators detected 35, and the Global Trigger Tool detected 354 events, ten times more than the AHRQ method.  In other words, the AHRQ indicators and voluntary reporting missed more than 90 percent of adverse events identified by the Global Trigger Tool.  If anything, the researchers say, their findings are conservative, because they rely on medical record review, which would not detect as many adverse events as direct, real-time observation would.

The researchers say that reliance on voluntary hospital reporting or the AHRQ indicators could lead to seriously flawed perceptions of patient safety in the United States.  They also note that the Global Trigger Tool detected a much higher rate of adverse events for hospitalized patients than previous studies have shown.  Although the Global Trigger Tool is a somewhat more resource-intensive method because it involves medical record review, the researchers suggest that it could be incorporated into commercial electronic health record systems, thus making it easier and less costly to use.

To read the full reporting please visit 

http://healthaffairs.org/blog/2011/04/07/new-health-affairs-hospital-errors-ten-times-more-common-than-thought/