WIHI: The Power to Detect and Reduce Harm: IHI’s Global Trigger Tool and Adverse Events in the US

Date: October 21, 2010
  • Lee Adler, DO, Vice President for Quality, Safety, Innovation, and Research, Florida Hospital
  • Ruth Ann Dorrill, MPA, Team Leader, Office of Inspector General, US Department of Health and Human Services
  • Amy Ashcraft, Senior Analyst, Office of Inspector General, US Department of Health and Human Services
  • Donald Goldmann, MD, Senior Vice President, Institute for Healthcare Improvement
  • Fran Griffin, Senior Manager of Clinical Programs for BD Medical/Medical Surgical Systems; Faculty, Institute for Healthcare Improvement
How often are patients harmed in US hospitals, and what is the best way to determine this? Ever since the Institute of Medicine (IOM) estimated that up to 98,000 patients die in hospitals each year due to medical errors, and some subsequent studies that claim the number is much higher, getting a more precise “national” handle on where and when and how frequently harm occurs has bedeviled most researchers. Without a baseline, it’s been impossible to state with any certainty whether patients are any safer today in US hospitals than they were ten years ago, when the IOM issued its seminal report.

This is the backdrop for a groundbreaking series of studies that the Office of Inspector General (OIG) at the Department of Health and Human Services has been undertaking. In the past two years, the OIG has issued a series of reports focused on harm that reaches hospitalized Medicare recipients, including analysis of the sensitivity and accuracy of methods for detecting harm. Its most recent report, slated for publication in October, provides a first-of-its-kind national incidence rate for adverse events.

IHI’s Global Trigger Tool, designed to facilitate a retrospective review of medical records to identify adverse events, combined with a physician review, has been singled out by the OIG as a powerful means of determining when an adverse event has occurred.

This WIHI offers a window into all the research findings — straight from the experts — and their significance for patient safety, harm detection, improvement work, and policy reform going forward.


Average Content Rating
(1 user)
Please login to rate or comment on this content.
User Comments