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

The Authority provides studies supporting the data in its latest Patient Safety Advisory and encourages healthcare facilities to implement suggested r

HARRISBURG, Pa., March 1, 2011 /PRNewswire-USNewswire/ -- Language barriers slow down access to healthcare, can compromise the quality of care and may increase the risk of harmful medical events among patients with limited English proficiency (LEP), according to data and research studies released today in the March 2011 Pennsylvania Patient Safety Advisory.

Events reported to the Pennsylvania Patient Safety Authority from June 2004 through May 2010 were reviewed to determine what types of events most frequently affect patients with LEP. Falls, errors related to a surgical procedure, and medication errors were the top three types of events reported for LEP patients during this time frame.

Of the 232 event reports, 114 (49%) involved patient falls, 62 (27%) involved errors or complications related to a surgical procedure, and 14 (6%) involved medication errors or adverse drug reactions. One hundred nine reports (47%) were for LEP patients over the age of 65. Of the 232 reports, 128 (55%) reports specifically mentioned the primary language spoken, whereas the remaining reports (104) did not. Where the language was specifically documented, Spanish was most frequently mentioned.

"The Authority data and research suggests that patients with a language barrier may be more susceptible to an adverse event than an English-speaking patient," Fran Charney, director of Educational Programs for the Pennsylvania Patient Safety Authority said. "In one report, a ten-year-old child was used as an interpreter for the patient which places a heavy burden on the child and put the patient at risk because the child may not have understood everything that was being said.

"There's too much room left for error in a case like that," Charney added.

She cited the top three events that affected LEP patients based on the reported events: 1) falls among LEP patients were often due to the patient not understanding or following instructions; 2) reports of errors or complications related to a surgical procedure showed problems with obtaining consent or locating an interpreter before the procedure, causing delays; and 3) medication errors or adverse drug reactions due to misinterpretation of instructions.

"The Authority research shows that communication issues have always been a significant contributing factor for adverse events in the healthcare system no matter what language is spoken," Charney said. "Whether you have patients or healthcare providers who speak a different language, facilities must take the necessary steps to prevent any miscommunication between patient and provider.

"Developing a written plan that identifies LEP individuals and measures that will be used, training staff, and notifying LEP patients that language assistance tools are available are important steps to making communication better among patients and healthcare providers," Charney added.

For more information about the studies and data regarding LEP patients go to the Advisory article "Managing Patients with Limited English Proficiency" at the Authority's website www.patientsafetyauthority.org.

The Authority's 2011 March Advisory also contains other clinical articles with toolkits for the healthcare provider to improve patient safety. Highlights include:

• Medication Errors in the Emergency Department: Of all care areas mentioned in medication error reports analyzed by the Authority, the emergency department (ED) is the third most commonly mentioned. Most common medication event types in the ED include wrong dose/overdosage, drug omission and wrong drug. For more research and risk reduction strategies on medication errors in the ED go to the Advisory article "Medication Errors in the Emergency Department: Need for Pharmacy Involvement?"
• More Precautions When Using Inferior Vena Cava (IVC) Filters: In 2010, the U.S. Food and Drug Administration (FDA) issued a device safety alert regarding retrievable IVC filters (devices implanted in patients at risk for life-threatening pulmonary embolism who cannot use anticoagulation therapy) that described types of adverse events involving filters. The Authority received 35 reports from June 2004 to November 2010 describing adverse events related to implanted IVC filters. This article "Indications for and Management of Inferior Vena Cava Filters" contains information on how healthcare facilities can reduce complications from the IVC filters.
• Falls in Radiology: Analysis of reports to the Authority in 2009 showed 602 falls events in radiology departments. These reports in 2009 were also more likely to cause harm than in falls reported in other departments. Falls were from stretchers, procedure tables, or stools, including during transfers. This article "Falls in Radiology: Establishing a Unit-Specific Prevention Program" gives risk reduction strategies to help facilities reduce falls particularly in radiology departments. An educational toolkit with an assessment tool to help radiology technologists determine falls risk is also available with this article.
• Improving the Safety of Negative-Pressure Wound Therapy (NPWT): Negative-pressure wound therapy is a noninvasive therapy that uses negative pressure to treat acute and chronic wounds. While it can be used safely as part of a comprehensive wound treatment program, 77 patient injuries and six deaths associated with NPWT have prompted the U.S. Food and Drug Administration to issue an alert to healthcare providers. The Authority received 419 reports related to the application or management of NPWT. Risk reduction strategies for clinicians to prevent patient harm when using NPWT can be found in this article "Improving the Safety of Negative-Pressure Wound Therapy." Consumer tips are also available for patients who are determined by their doctor to be able to use NPWT at home.
• Skin and Soft-Tissue Infections (SSTIs) in Long-Term Care: Skin and soft-tissue infections are the third most common infection in nursing home residents nationally. From July 2009 through June 2010, Pennsylvania nursing homes reported a total of 5,881 SSTI events. Consistent with national data findings, these reports show that cellulitis (bacterial infection below the surface of the skin) and decubitus ulcer (bed sore) infections were the most commonly reported. This article "Skin and Soft-Tissue Infections in Long-Term Care" gives risk reduction strategies for caregivers.
• Wrong-Site Surgery Update: To answer the question of how much progress is being made in the wrong-site surgery project, the Authority did a comprehensive review of all Serious Event and Incident reports from June 2004 (when reporting began) to December 31, 2010. This article gives the detailed analysis and findings that show while there is some progress; it's not being made quickly enough. More insight is given about the causes of wrong-site surgery in this article. A toolkit is also available on the Authority's website for healthcare facilities to prevent wrong-site surgery.

For the complete 2011 March Pennsylvania Patient Safety Advisory, go to www.patientsafetyauthority.org.

PATIENT SAFETY AWARENESS WEEK

NPSF ANNOUNCES 2011 PATIENT SAFETY AWARENESS WEEK

BOSTON, MA (March 7, 2011) – The National Patient Safety Foundation (NPSF) is celebrating Patient Safety Awareness Week on March 6-12; this annual event is designed to highlight improved patient-provider communication as a vital part of keeping patients safe. This year, NPSF is also focusing on efforts to reduce medication errors and lower hospital readmission rates. As the nation’s leading voice for patient safety, NPSF’s goal for the campaign is to encourage improved patient care through better communication among providers, patients, families, and communities.

“Patient Safety Awareness Week underscores the needs addressed by national discussions on patient safety and emphasizes the value of collective effort and working together for making and keeping our health care system safe,” says Diane C. Pinakiewicz, president of NPSF.

According to a New England Journal of Medicine study analyzing close to 12 million fee-for-service Medicare beneficiaries, nearly 20 percent of those discharged from a hospital were re-admitted within 30 days; 34 percent were re-hospitalized within 90 days, and 54 percent, within a year. Medication errors played a large, preventable role in these readmissions.

In support of Patient Safety Awareness Week this year, NPSF has made available a variety of online resources expressly designed to help patients understand what they can do and what they need to know to stay safe. Patients and families interested in learning more should visit www.npsf.org.

In addition, the Ask Me3^TM program is again an integral component of Patient Safety Awareness Week. This health literacy initiative is designed to assist with communication between patients and providers by way of three basic questions – “What is my main problem?” “What do I need to do?” and “Why is it important for me to do this?”

Patient Safety Awareness Week, which NPSF has been leading since 2002, is intended to raise public awareness about the work being done to improve patient safety and the importance of effective partnering in these improvement efforts. It is also an effort to directly involve patients and health care consumers in the process of ensuring that health care errors do not occur.

Health care organizations nationwide and around the world are displaying and distributing Patient Safety Awareness Week materials and resources, including posters, brochures, stickers, and lapel buttons to demonstrate their support and commitment.