The research findings appear in the November 25, 2010 issue of the New England Journal of Medicine.
The researchers chose to look at hospitals in North Carolina because the state has shown a strong commitment to patient safety. Teams of reviewers, from within and outside the study hospitals, using the IHI’s Global Trigger Tool, sorted through patient medical records from 2,341 randomly selected hospital admissions between 2002 and 2007 searching for trigger events that suggested harm had occurred. They found 588 instances of patient harm.
Total harm rates remained consistent throughout the study at approximately 25 harms per 100 hospital admissions. While most harms were minor and reversible, 50 were categorized as life-threatening, 17 resulted in permanent harm and 14 deaths were attributed to medical errors.
“The study is a call to action for hospitals and the health care system. While progress has been made over the past decade in understanding the causes and consequences of medical errors, we have a long way to go. A coordinated, comprehensive strategy for reducing harm due to medical care nationwide is urgently needed,” said Christopher P. Landrigan, MD, MPH, lead author of the study and from the Division of Sleep Medicine at BWH and the Division of General Pediatrics at Children’s Hospital Boston. “Some of the interventions that appear most promising, such as implementing care bundles to reduce hospital-acquired infections, limiting the work hours of medical staff, and computerized provider order entry have not been implemented in most hospitals. A nationwide investment is needed to ensure that these best practices are widely adopted.”
There is some good news, however. “Perhaps the most important finding of this study was that the trigger tool can be used to track harm reliably over time at a regional, or perhaps even a national level,” said Landrigan. “If hospitals and patient safety organizations (PSOs) nationwide were to begin reporting data on harm rates using this standardized method, we would have a much clearer picture of the safety of the U.S. healthcare system, and would be better positioned to identify and share improvements that are being made.”
The study was funded by the Rx Foundation and supported by the Institute for Healthcare Improvement.