title: 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured.
abstract: 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. We compared three methods to detect adverse events in hospitalized patients, using the same patient sample set from three leading hospitals. We 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 ten 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 US health care system and misdirect efforts to improve patient safety.
authors.affiliation: University of Utah, Salt Lake City, Utah, USA. dclassen@csc.com
authors.forename: David C
authors.initials: DC
authors.lastname: Classen
authors.forename: Roger
authors.initials: R
authors.lastname: Resar
authors.forename: Frances
authors.initials: F
authors.lastname: Griffin
authors.forename: Frank
authors.initials: F
authors.lastname: Federico
authors.forename: Terri
authors.initials: T
authors.lastname: Frankel
authors.forename: Nancy
authors.initials: N
authors.lastname: Kimmel
authors.forename: John C
authors.initials: JC
authors.lastname: Whittington
authors.forename: Allan
authors.initials: A
authors.lastname: Frankel
authors.forename: Andrew
authors.initials: A
authors.lastname: Seger
authors.forename: Brent C
authors.initials: BC
authors.lastname: James
mesh_terms: D005260:Female; D017052:Hospital Mortality; D006761:Hospitals; D006801:Humans; D008297:Male; D008485:Medical Audit; D019300:Medical Errors / Q000706:statistics & numerical data*; D008875:Middle Aged; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology