Using the Institute for Healthcare Improvement's Global Trigger Tool, this retrospective study analyzed adverse events at a large health care system in Texas. Approximately one-third of patients experienced at least one adverse event during their hospital stay. The vast majority of these incidents were deemed potentially preventable. Surgical and procedural complications accounted for a large portion of adverse events in the hospital. Less than 5% of the hospital-acquired adverse events identified in this study would have been discovered through voluntary reporting or use of AHRQ Patient Safety Indicators, illustrating the challenges of detecting safety hazards. A previous AHRQ PSNet interview with Dr. David Classen explored the use of trigger tools to measure patient safety.

… for Healthcare Improvement's Global Trigger Tool is a widely used approach for detecting and monitoring safety … of the Global Trigger Tool, with the goal of developing a sustainable mechanism for identifying adverse events (AEs), …

In this study, implementation of system-wide training and adoption of the structured communication tool SBAR were associated with challenges in uptake and physician education. However, in situations where SBAR was used correctly, physicians were more likely to be able to make clinical decisions.

This review of computerized physician order entry, clinical decision support systems, and bar-coded medication administration discusses the risks created by health care information technology.

… Quality … Am J Med Qual … This commentary describes a process structured around improving safety culture and …