A New Evidence-based Estimate of Patient Harms

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A New, Evidence-based Estimate of Patient Harms
Associated with Hospital Care
John T. James, PhD

Objectives: Based on 1984 data developed from reviews of medical records of patients treated in New York hospitals, the Institute of Medicine estimated that up to 98,000 Americans die each year from medical errors. The basis of this estimate is nearly 3 decades old; herein, an updated estimate is developed from modern studies published from 2008 to 2011.

Methods: A literature review identified 4 limited studies that used primarily the Global Trigger Tool to flag specific evidence in medical records, such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient. Ultimately, a physician must concur on the findings of an adverse event and then classify the severity of patient harm.

Results: Using a weighted average of the 4 studies, a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals. Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm. Conclusions: The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed. Fully engaging patients and their advocates during hospital care, systematically seeking the patients’ voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary to accomplish this goal. Key Words: patient harm, preventable adverse events, transparency, patient-centered care, Global Trigger Tool, medical errors

(J Patient Saf 2013;9: 122Y128)

‘‘All men make mistakes, but a good man
yields when he knows his course is wrong,
and repairs the evil. The only crime is
pride.’’V Sophocles, Antigone’’


the national level. The amount of new knowledge generated
each year by clinical research that applies directly to patient care can easily overwhelm the individual physician trying to optimize the care of his patients.1 Furthermore, the lack of a wellintegrated and comprehensive continuing education system in the health professions is a major contributing factor to knowledge and performance deficiencies at the individual and system level.2 Guidelines for physicians to optimize patient care are quickly out of date and can be biased by those who write the guidelines.3Y5 At the system level, hospitals struggle with staffing issues, making suitable technology available for patient care, and executing effective handoffs between shifts and also between inpatient and outpatient care.6 Increased production demands in cost-driven institutions may increase the risk of preventable adverse events (PAEs). The United States trails behind other developed nations in implementing electronic medical records for its citizens.7 Hence, the information a physician needs to optimize care of a patient is often unavailable.

At the national level, our country is distinguished for its
patchwork of medical care subsystems that can require patients to bounce around in a complex maze of providers as they seek effective and affordable care. Because of increased production demands, providers may be expected to give care in suboptimal working conditions, with decreased staff, and a shortage of

physicians, which leads to fatigue and burnout. It should be no surprise that PAEs that harm patients are frighteningly common in this highly technical, rapidly changing, and poorly integrated industry. The picture is further complicated by a lack of transparency and limited accountability for errors that harm patients.8,9 There are at least 3 time-based categories of PAEs recognized in patients that are or have been hospitalized. The broadest...
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