To report 5 years of adverse events (s) identified using an enhanced Global Trigger Tool () in a large health care system.
Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.
We examined incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used ‐detection systems.
Professional nurse reviewers abstracted 9,017 records using the enhanced , recording triggers and s. Medical record/account numbers were matched to identify overlapping voluntary reports or Patient Safety Indicators (s).
Estimated rates were as follows: 61.4 s/1,000 patient‐days, 38.1 s/100 discharges, and 32.1 percent of patients with ≥1 . Of 1,300 present‐on‐admission s (37.9 percent of total), 78.5 percent showed ‐ level F harm and 87.6 percent were “preventable/possibly preventable.” Of 2,129 hospital‐acquired s, 63.3 percent had level E harm, 70.8 percent were “preventable/possibly preventable”; the most common category was “surgical/procedural” (40.5 percent). Voluntary reports and s captured <5 percent of encounters with hospital‐acquired s.
s are common and potentially amenable to prevention. ‐identified s are seldom caught by commonly used ‐detection systems.
