Hospital errors under a microscope loom larger than ever

By ACSH Staff — Apr 08, 2011
A new study would have you believe that hospital errors are ten times the rate that was once reported. Researchers from the University of Utah tested a new hospital error detection protocol developed by the Institute for Healthcare Improvement in Massachusetts against an already-established method developed by the U.S. Agency for Healthcare Research and Quality (AHR) and a voluntary reporting system.

A new study would have you believe that hospital errors are ten times the rate that was once reported. Researchers from the University of Utah tested a new hospital error detection protocol developed by the Institute for Healthcare Improvement in Massachusetts against an already-established method developed by the U.S. Agency for Healthcare Research and Quality (AHR) and a voluntary reporting system. The new method found that among 795 patient files, 354 “events” occurred compared with four complications found through voluntary reporting and 35 with the AHR method.

“What bothers me,” says ACSH's Dr. Gilbert Ross, “is that the researchers are making up their own metric. If it’s finding ten-times more errors, they are probably using a microscope instead of a magnifying lens, so to speak. I doubt all of these errors will actually affect patient outcomes. I’m sure it’s true that many errors still go undetected, but even so, not all of them can be dealt with systemically. For instance, a nurse can still give the wrong medication to a patient, even if all of the established safety protocols are followed. Plus, a less-than-800-records sample is not likely to yield the most reliable data.”

The take-home message, says ACSH’s Cheryl Martin, is that, “Patients need to be more proactive during their hospital stay — ask questions and have a say in their caregivers’ medical decisions to improve their chances of receiving the correct treatment. Having a friend or family member around as an advocate is also very helpful”

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