Identification and measurement of adverse medical events is central to patient safety, forming a foundation for accountability, prioritizing problems to work on, generating ideas for safer care, and testing which interventions work.
These researchers compared three methods to detect adverse events in hospitalized patients, using the same patient sample set from three leading hospitals. They found that the adverse event detection methods commonly used to track patient safety in the United States today—voluntary reporting and the Agency for Healthcare Research and Quality’s Patient Safety Indicators—fared very poorly compared to other methods and missed 90 percent of the adverse events. The Institute for Healthcare Improvement’s Global Trigger Tool found at least 10 times more confirmed, serious events than these other 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 U.S. health care system and misdirect efforts to improve patient safety.
- 1. The Ongoing Quality Improvement Journey
- 2. A Road Map for Improving the Performance of Performance Measures
- 3. Global Trigger Tool' Shows that Adverse Events in Hospitals May be Ten Times Greater Than Previously Measured
- 4. Preventing Bloodstream Infections
- 5. Measuring the Performance of Individual Physicians by Collecting Data from Multiple Health Plans
- 6. Measuring Health Care Performance Now, Not Tomorrow
- 7. Despite Improved Quality of Care in the Veterans Affairs Health System, Racial Disparity Persists for Important Clinical Outcomes
- 8. The Importance of Transitional Care in Achieving Health Reform
- 9. An Early Status Report on the Beacon Communities' Plans for Transformation Via Health Information Technology
- 10. A Comparative Study of 11 Local Health Department Organizational Networks
- 11. Public Health Performance
- 12. A Self-Assessment Process for Accreditation Preparedness
- 13. Public Health Delivery Systems
- 14. Regionalization in Local Public Health Systems
- 15. A Shot in the Rear, Not a Shot in the Dark
- 16. What Predicts Local Public Health Agency Performance Improvement?
- 17. Growth of a Scientific Community of Practice
- 18. Evolution of Coauthorship in Public Health Services and Systems Research
- 19. Resources that May Matter
- 20. Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths
- 21. Public Health Financial Management Competencies
- 22. Decision Science
- 23. Public Health Financial Management Needs
- 24. Data-Driven Management Strategies in Public Health Collaboratives
- 25. Using Geographic Information Systems to Match Local Health Needs with Public Health Services and Programs
- 26. Public Health Systems and Services Research
- 27. Mapping the Multidisciplinary Field of Public Health Services and Systems Research