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ADVANCE Perspective: Nurses

Medical Errors: A New Yardstick Reveals More Problems

Published April 11, 2011 9:13 AM by Linda Jones
The Institute of Medicine report To Err Is Human, brought to light, to both healthcare professionals and the public, serious changes needed in healthcare delivery in this country. Although the report is more than 10 years old, it's still referenced and used as a tool for identifying areas where new processes are needed.

Never Events from CMS are part of what resulted from the IOM report, as were the creation of tools and systems hospitals can purchase to reduce the number of errors - and provide better patient care. While many facilities have invested in these tools and claim to be making progress, a study finds that the original measurements were off - significantly, which means hospitals aren't doing as good a job as they think they are.

The new tool, called the Global Trigger Tool, which uses systematic surveillance of medical records, reveals errors are about 10 times higher than estimates using older methods.

The study that revealed this was conducted by David Classen, MD, of the University of Utah and colleagues who compared their new quality yardstick, developed at the Institute for Healthcare Improvement in Massachusetts, to two older methods: one that looked at voluntary statements of error made in medical records, and an older method developed by the U.S. Agency for Healthcare Research and Quality.

In fact, Classen has been making this claim for years. From a 2000 interview with Managed Care Magazine, Classen says: "We found that the [IOM] study underestimated the problem of adverse effects fivefold. So it's a much larger problem."

The study looked at 795 patient records using the three methods. Voluntary reporting detected four problems, the Agency for Healthcare Research's quality indicator found 35, and the Institute for Healthcare Improvement's tool detected 354 events.

With the Global Trigger Tool, closed patient charts are reviewed by two or three people trained in the method. They look at discharge codes, discharge summaries, medications, lab results, operation records, nursing notes, physician progress notes, and other notes or comments to determine whether there is a "trigger" in the chart. "A trigger could be a notation indicating, for example, a medication stop order, an abnormal lab result, or use of an antidote medication," according to the study. The trigger leads to further investigation.

It was shocking enough in 1999 to learn how many errors are made in U.S. hospitals, and to learn now that it's so much worse is discouraging and frustrating - and scary. Reuters claims, "one in three people in the United States will encounter some kind of mistake during a hospital stay."

We can read the studies and listen to the theories of what needs to be done - but you are there. You know how the system works. What's wrong? Is it workload, access to resources, quality of caregivers, education?

Why are so many mistakes being made in hospitals today?




posted by Linda Jones


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