Press Release

Embargoed Until Contact

April 07, 2011
12:01 AM EST

Sue Ducat
Director of Communications
(301) 841-9962


New Study Finds Up To Ten Times More Hospital Errors Than Other Methods Have Detected


Despite A Focus on Patient Safety, Large Risks, High Costs, And Gaps In Health Care Quality Persist, According To April Health Affairs


Bethesda, MD--Despite more than a decade of national focus on patient safety, medical errors and other adverse events occur in one-third of hospital admissions--as much as ten times more than some previous estimates have indicated, according to authors of a new study in the April issue of Health Affairs.


The study is one of several articles in this month's Health Affairs that address persistent challenges facing the US health care system with respect to closing the gaps in quality and safety of care--challenges identified as far back as 2001 by the Institute of Medicine's landmark report, Crossing the Quality Chasm. This thematic issue of the journal also looks at the profound costs incurred by shortfalls in quality; the optimal ways to measure quality; and the most successful ways to date of improving the quality of care. Taken together, the Health Affairs papers portray a mixed picture of health care quality in the United States. The Robert Wood Johnson Foundation, the nation's largest philanthropy focused solely on health and health care, sponsored the issue.


"Without doubt, we've seen improvements in health care over the past decade, and even pockets of excellence, but overall progress has been agonizingly slow," said Health Affairs Editor-in-Chief Susan Dentzer. "It's clear that we still have a great deal of work to do in order to achieve a health care system that is consistently high-quality--that is, safe, effective, patient-centered, efficient, timely, and devoid of disparities based on race or ethnicity."


The patient safety study, conducted by David C. Classen of the University of Utah and coauthors at the Institute for Healthcare Improvement, compared three methods for detecting adverse events in hospitalized patients, including the Institute's own Global Trigger Tool. The study drew on comparable samples of patients from three leading hospitals that had undertaken quality and safety improvement efforts.

Among the 795 patient records reviewed, voluntary reporting detected four events, the Agency for Healthcare Research and Quality (AHRQ) Indicators detected 35, and the Global Trigger Tool detected 354 events, ten times more than the AHRQ method. In other words, the AHRQ indicators and voluntary reporting missed more than 90 percent of adverse events identified by the Global Trigger Tool. If anything, the researchers say, their findings are conservative, because they rely on medical record review, which would not detect as many adverse events as direct, real-time observation would.


The researchers say that reliance on voluntary hospital reporting or the AHRQ indicators could lead to seriously flawed perceptions of patient safety in the United States. They also note that the Global Trigger Tool detected a much higher rate of adverse events for hospitalized patients than previous studies have shown. Although the Global Trigger Tool is a somewhat more resource-intensive method because it involves medical record review, the researchers suggest that it could be incorporated into commercial electronic health record systems, thus making it easier and less costly to use.

Other Health Affairs papers that examine the current state of US health care quality include:

  • An analysis by Jill Van Den Bos and colleagues at Milliman's Denver Health practice in Colorado, based on insurance claims, estimated the annual cost of measurable preventable medical errors that harm patients to be $17.1 billion in 2008 dollars. Ten types of errors accounted for more than two-thirds of the total cost, with the most common ones being pressure ulcers, postoperative infections, and persistent back pain following back surgery. The researchers recommend that these three types of errors receive top priority for intervention and improvement.

  • John C. Goodman of the National Center for Policy Analysis, and coauthors, found that there is a social cost to adverse events, and it is based on what people would be willing to pay to avoid the risk of death or injury caused by medical management. That dollar figure ranges from $393 billion to $958 billion. Yet the United States has few policies to compensate patients harmed by medical errors, other than a "very imperfect tort system," in which fewer than 2 percent of patients harmed ever file a malpractice suit and even fewer receive any compensation, the researchers note.

  • Widespread and serious racial and ethnic disparities in health care have previously been well-documented. Amal N. Trivedi of the Providence Veterans Affairs (VA) Medical Center and Brown University, along with several colleagues, studied the VA's efforts to combat disparities. They found that although care "process" outcomes--such as rates of eye exams for people with diabetes--improved, disparities in health outcomes--such as control of blood pressure, glucose, and cholesterol-- persisted. The difference between the clinical outcomes of black veterans as those of white veterans was as much as nine percentage points. The authors call for more focused efforts to achieve racial equity for more complex measures of chronic disease management.

Measuring Quality Improvement
Several papers explore health care quality changes related to data capture, performance measurement and performance reporting:


  • Peter J. Pronovost of Johns Hopkins University and Richard Lilford of the University of Birmingham in England observe the tension between scientists focused on ensuring the validity of various performance measures and policy makers pushing to use performance measurement to protect the public. Before such data can be used effectively, the authors say, "the health care industry must determine acceptable levels of validity and reliability" and policy makers must invest in advancing the science.

  • Tracy E. Spinks at the MD Anderson Cancer Center, University of Texas, and colleagues describe the need for measures that capture the complexities of cancer care as well as for health information technology systems and other methods to advance meaningful reporting of cancer care quality.

  • Harold Alan Pincus of Columbia University and colleagues outline a strategy for bringing mental health and substance use treatment into the mainstream of health care quality. Robust measures are only a first step, they say, to achieving a framework for behavioral health care quality.

Note: Also see Case Studies for more leading health care delivery systems chronicle lives saved, lowered health care-associated infection rates, and other quality improvements while reducing health care costs.


The Way Forward
Other papers in the issue describe key components of future quality improvement efforts and challenges that lie ahead:


  • In order to achieve a high-quality health care system, financial incentives must be aligned with health care performance. Rachel M. Werner of the University of Pennsylvania and colleagues studied the effects of Medicare's largest pay-for-performance hospital demonstration project, the CMS/Premier Hospital Quality Incentive Demonstration. The findings suggest that, while hospital quality did improve under the demonstration, by the end of the experiment, other hospitals not in the demonstration had caught up. The authors recommend ways to fine-tune pay-for-performance programs to have an even greater impact on health care quality.

  • To make the next big leap in quality, we must focus on achieving "high reliability"--achieving consistently high levels of safety and quality over time and across all health care services and settings--according to Mark R. Chassin and Jerod M. Loeb, both of the Joint Commission. The authors describe a framework for "high reliability," drawn from studies of extremely safe organizations outside health care, which is characterized by an attitude of "collective mindfulness" to quality and patient safety.

  • Floyd J. Fowler, Jr., of the Foundation for Informed Medical Decision Making, notes that patients need to be pulled more deeply into the quality improvement process as well, by routinely informing them about risks and benefits of care and by involving them deeply in making decisions about their health care.
About Health Affairs

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears each month in print, with additional Web First papers published weekly at You can also find the journal on Facebook and Twitter and download Narrative Matters on iTunes. Address inquiries to Sue Ducat at (301) 841-9962 or