NEW MEASUREMENT TOOL MAY (NOT) IMPROVE PATIENT SAFETY (CONCL.)

April 1, 2011

We’re continuing our discussion of a new tool to measure medical errors in hospitals. The Global Trigger Tool provides a more thorough review of hospital records, unveiling in one study 90 percent more errors than traditional review methods. These measurement tools provide the basis for hospital quality ratings and programs sponsored by organizations like Oregon’s Patient Safety Commission.

The researchers say they developed the Global Trigger Tool in an effort to be more in sync with the times. The measurement tools recommended by the U.S. Agency for Healthcare Research and Quality (AHRQ), for example, were developed for the old hospital care model. Patients no longer stay overnight for routine surgeries; rather, they’re taken care of in outpatient centers. As a result, only very ill people with complex or more serious medical issues are taking up hospital beds. These more complicated cases present more opportunities for errors in medication or procedures. Any quality data gathered would be skewed.

The study results bear this out to some degree. The most common errors were medication errors, surgical and nonsurgical procedure errors and common infections.

Health professionals who are less enthusiastic about the Global Trigger Tool admit that these are, indeed, common errors. They also say that these errors are the least severe. Perhaps the tool finds more data but provides less useful information.

The point of a patient safety program is to improve health outcomes for patients. The Global Trigger Tool may identify a huge number of errors, but it doesn’t rank them in terms of patient consequences.

All safety advocates agree that the best reporting method would be direct, real-time observation. Voluntary reporting can certainly lead to under-reporting — that’s why government and private safety organizations audit hospital records. This new tool may provide too much data, while more traditional tools are able to rank results.

The Oregon Patient Safety Commission is working to ensure that the state’s health care system is the safest in the nation. The Global Trigger Tool adds another instrument to the orchestra.

Source: U.S. News & World Report, “Report: Hospital Errors May Be Far More Common Than Suspected,” Steven Reinberg, 04/07/11

 

Categories: Blog