Despite numerous studies over the past three decades, one fundamental patient safety question remains controversial: what proportion of hospitalized patients are harmed by medical care? Prior estimates range from approximately 3% to nearly 17%, but this study found that nearly one-third of patients experienced an adverse event during hospitalization. This study used the Institute for Healthcare Improvement's Global Trigger Tool to detect adverse events and also found that this trigger tool identified significantly more adverse events than voluntary reporting or the AHRQ Patient Safety Indicators. An important caveat is that this study did not assess whether the adverse events detected were preventable. Nevertheless, the results do raise the concern that adverse events remain common despite enhanced safety efforts. The challenges of accurately measuring patient safety events were discussed in an AHRQ WebM&M perspective.

A National Patient Safety Goal (NPSG) since 2005, medication reconciliation involves verifying medications and dosages as well as documenting and explaining medication changes. Medication reconciliation has been notoriously difficult to accomplish in both inpatient and outpatient settings. The Joint Commission currently does not evaluate medication reconciliation in accreditation surveys. This consensus statement, endorsed by The Joint Commission and other major professional societies, calls for recasting medication reconciliation in a patient-centered, patient safety–oriented fashion. Several key steps to develop effective and usable reconciliation tools include multidisciplinary involvement with clear roles among clinicians, patient-centered measurement strategies, and rigorous study and dissemination of implementation strategies. The findings of this consensus group will be used in the revised medication reconciliation NPSG, which will be issued in 2011.

This study found satisfactory reliability between internal and external reviewers using the IHI Global trigger tool to identify adverse hospital events.

This commentary describes five key components of care recommended by IHI as the most effective methods to prevent hospital-acquired infections in intensive care settings.

The author supports the Institute for Healthcare Improvement’s 5 Million Lives Campaign by recommending several changes in care outlined in the Surgical Care Improvement Project (SCIP), including minimal practice variation, improved teamwork and communication, and increased reliability in processes.

The authors discuss the objectives of the 5 Million Lives Campaign and highlight the program's six new interventions to improve patient safety.