Are Our Hospital Safe?

‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured

1. David C. Classen1,*,
2. Roger Resar2,
3. Frances Griffin3,
4. Frank Federico4,
5. Terri Frankel5,
6. Nancy Kimmel6,
7. John C. Whittington7,
8. Allan Frankel8,
9. Andrew Seger9 and
10. Brent C. James10

+Author Affiliations

1. ¹David C. Classen (dclassen@csc.com) is an associate professor of medicine at the University of Utah, in Salt Lake City.
2. ²Roger Resar is a senior fellow at the Institute for Healthcare Improvement, in Cambridge, Massachusetts.
3. ³Frances Griffin is a faculty member at the Institute for Healthcare Improvement.
4. ⁴Frank Federico is an executive director at the Institute for Healthcare Improvement.
5. ⁵Terri Frankel is a director at the Institute for Healthcare Improvement.
6. ⁶Nancy Kimmel is director of quality and safety at the Missouri Baptist Medical Center, in St. Louis.
7. ⁷John C. Whittington is a senior fellow at the Institute for Healthcare Improvement.
8. ⁸Allan Frankel is an associate professor at Brigham and Women’s Hospital, in Boston, Massachusetts.
9. ⁹Andrew Seger is an assistant professor at Brigham and Women’s Hospital.
10. ¹⁰Brent C. James is chief quality officer at Intermountain Healthcare, in Salt Lake City, Utah.

1. ↵*Corresponding author

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