April 1, 2011

Oregon’s Patient Safety Commission has set an ambitious goal: Oregon will have the safest healthcare delivery system in the nation. To get there, the state will have to eliminate preventable harm events — there will be no medication errors, no surgical instruments left in patients, no preventable infections. The commission has been measuring these adverse events for a few years now, reporting mixed progress.

A research team has developed a tool that could help analysts more accurately measure medical mistakes and more accurately determine if we’re closer to our goal.

The team tested the Global Trigger Tool in a review of 795 patient records. They compared their results with the results found by traditional measurement tools. What they found will certainly grab the attention of Oregon’s patient safety advocates: The Global Trigger Tool found 10 times more errors than the usual tools found.

For the most part, the U.S. Agency for Healthcare Research and Quality (AHRQ) governs which measurement tools hospitals use. These tools generally include voluntary reporting systems and coding systems for chart review programs. These time-honored tools missed 90 percent of the errors, though.

The comprehensive review offered by the Global Trigger Tool identified 354 errors in the study’s 795 patient records. The AHRQ methods found 35.

The lead researcher points out that there’s always room for improvement, and when you’re talking about patient safety, finding the most accurate measure of errors should translate into better patient outcomes.

Critics don’t completely agree, though. We’ll get into that in our next post.

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


Categories: Blog