The hospital isn’t really ever a place you want to be. Granted, that’s changed a lot over the last several decades, back when hospitals were just places people went to die. Now, at least, hospitals are places many people go to get better, but they’re still dangerous. All sorts of bad things, known as “adverse events,” can happen within the walls of the hospital. You can catch a nosocomial (hospital-acquired) infection. You can take the wrong medication or too much or too little of the right medication. You can have the wrong leg amputated in surgery. You can be the wrong patient in surgery to begin with. You can develop pressure sores if you are stuck in bed for too long. You can slip and fall if you get out of bed too soon. The list goes on and on.
Identifying these adverse events, so that they may be prevented in the future, is a key aspect of improving health care quality. A recent Health Affairs article by Classen et al. compares several different methods for identifying adverse events. For the layperson, the take home message is: Adverse events are much more common than previously thought. It all depends on how attempts are made to measure them. As it turns out, the Global Trigger Tool developed by the Institute for Healthcare Improvement finds a lot more adverse events than any of the other widely used methods, including one developed by the Agency for Healthcare Research and Quality (AHRQ). What kind of difference are we talking about? Well, in a review of 795 patient records, AHRQ’s method identified 35 adverse events. The Global Trigger Tool identified 354 adverse events. That is what we in the business call “an order of magnitude.” And, compared to local hospital reporting systems that identified only 4 adverse events, we’re talking about two orders of magnitude (i.e., about a 100-fold difference). Just when you thought it was safe to go back in the water…..