Above is an April 7, 2011, headline from the Bloomberg news service. The article reported on a study published in Health Affairs in April, 2011, which showed that using a more exact measurement of recording medical errors drastically increased the recorded estimation of the probable medical errors that occur.
Study author David C. Classen, MD, an associate professor of medicine at the University of Utah in Salt Lake City, notes that most hospitals use a voluntary reporting system for errors and adverse events using criteria set by the Agency for Healthcare Research and Quality’s Patient Safety Indicators. Classen and his researchers believe that this current system misses 90 percent of all errors.
The researchers wrote, “Hospitals that use such methods alone to measure their overall performance on patient safety may be seriously misjudging actual performance. Reliance on such methods could produce misleading conclusions about safety in the U.S. health-care system and could misdirect patient-safety improvement efforts.”
In his comments on the study in an April 9, 2011 USA Today article Dr. Classen explained, “The more you look for errors, the more you find.” He continued, “There is a large opportunity for improvement, despite all the work that’s been done. And we need better measurement systems to assess how we are doing in patient safety.”
In the USA Today article, Dr. John Birkmeyer, director of the Center for Healthcare Outcomes and Policy at the University of Michigan, stated that he was not surprised that the research showed that so many medical errors are being missed. He said, “Nobody is surprised that systems that rely on voluntary reporting would tend to let a high percentage of cases fall through the cracks. It’s not a surprise that a method based on careful chart abstraction by knowledgeable reviewers would do a much better job in tracking adverse events.”
The Bloomberg article brought forth some sobering statistics in the light of this study. They noted that according to this study, adverse events occur in one-third of hospital admissions. A 1999 report by the U.S. Institute of Medicine found that medical errors caused as many as 98,000 deaths and more than 1 million injuries each year. This was using the old method of error reporting. The Bloomberg article also noted that a similar study published in November of 2010 in the New England Journal of Medicine, looking at hospital admissions in North Carolina, found that almost one-in-five patients were injured by their care.