1 in 3 Hospitalized Patients Suffers an Adverse Event

Cheryl Clark, for HealthLeaders Media , April 7, 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.

"Overall, adverse events occurred in 33.2% of hospital admissions (range: 29% to 36%) or 91 events per 1,000 patient days," says the lead author, David Classen, MD, associate professor of medicine at the University of Utah in Salt Lake City.

Imagine telling a hospital patient on admission that they have a one in three risk of suffering some harm from an error unrelated to the condition or disease that brought them there. It's almost enough to make you forget about accountable care organizations, or that there ever was talk about bending the cost curve.

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2 comments on "1 in 3 Hospitalized Patients Suffers an Adverse Event"

Martine Ehrenclou (4/8/2011 at 3:48 PM)
It is a sad state of affairs but there is much a patient can do to help prevent medical errors. First, enlist the help of a loved one to act as your advocate to help oversee and monitor your hospital medical care. Each time you have a new medical encounter, repeat your full name and date of birth. Ask the medical professional to check. I wrote a book about how to survive a hospital stay and it's full of strategies. If we work in collaboration with the hospital medical staff, we have a better chance of eliminating more medical errors. This is a team effort. My book is Critical Conditions: The Essential Hospital Guide To Get Your Loved One Out Alive.

Barry Bodie (4/7/2011 at 1:38 PM)
After doing this for nearly thirty years, I am amazed that no matter how careful you are, how much you try to prevent adverse consequences or how diligently you watch things, people are still going to have problems because of worn out immune systems, aging and the ravages of untreated and often ignored disease. Are we going to punish doctors for pulmonary embolism in an obese, smoking diabetic, lung cancer patient requiring ventilatory support because of a community acquired pneumonia. Why are we listing wound infections in patients operated on for diverticular abscesses or gangrenous gallbladders? All this is not in the interest of treating patients as they come to use, but in the interest of saving money at the expense of good medical care.




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