Global Trigger Tool' Shows that Adverse Events in Hospitals May be Ten Times Greater Than Previously Measured

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.

April Issue of Health Affairs Focuses on Patient Safety and Health Care Quality

  1. 1. The Ongoing Quality Improvement Journey
  2. 2. A Road Map for Improving the Performance of Performance Measures
  3. 3. Global Trigger Tool' Shows that Adverse Events in Hospitals May be Ten Times Greater Than Previously Measured
  4. 4. Preventing Bloodstream Infections
  5. 5. Measuring the Performance of Individual Physicians by Collecting Data from Multiple Health Plans
  6. 6. Measuring Health Care Performance Now, Not Tomorrow
  7. 7. Despite Improved Quality of Care in the Veterans Affairs Health System, Racial Disparity Persists for Important Clinical Outcomes
  8. 8. The Importance of Transitional Care in Achieving Health Reform
  9. 9. An Early Status Report on the Beacon Communities' Plans for Transformation Via Health Information Technology
  10. 10. A Comparative Study of 11 Local Health Department Organizational Networks
  11. 11. Public Health Performance
  12. 12. A Self-Assessment Process for Accreditation Preparedness
  13. 13. Public Health Delivery Systems
  14. 14. Regionalization in Local Public Health Systems
  15. 15. A Shot in the Rear, Not a Shot in the Dark
  16. 16. What Predicts Local Public Health Agency Performance Improvement?
  17. 17. Growth of a Scientific Community of Practice
  18. 18. Evolution of Coauthorship in Public Health Services and Systems Research
  19. 19. Resources that May Matter
  20. 20. Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths
  21. 21. Public Health Financial Management Competencies
  22. 22. Decision Science
  23. 23. Public Health Financial Management Needs
  24. 24. Data-Driven Management Strategies in Public Health Collaboratives
  25. 25. Using Geographic Information Systems to Match Local Health Needs with Public Health Services and Programs
  26. 26. Public Health Systems and Services Research
  27. 27. Mapping the Multidisciplinary Field of Public Health Services and Systems Research