Office of Inspector General (OIG)

...The following year, researchers shook the profession with an article in Health Affairs entitled “‘Global Trigger Tool’ Shows that Adverse Events in Hospitals May be Ten Times Greater than Previously Measured.” Dr. David Classen, who did the seminal research for global triggers, served as lead author of the study, which looked at three mid-size to large (ranging from 550 to 1,000 beds) teaching hospitals associated with medical schools in the West and Northwest that participated on the condition of anonymity...When different detection methods were applied, global triggers found over 90 percent of events, the government’s Patient Safety Indicators (based on discharge summaries) found 8.5 percent, and voluntary reporting disclosed only 2 percent (afraid of censure and malpractice, doctors and nurses seldom willingly self-accuse). Classen, et al. warned: “reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the U.S. health-care system and misdirect efforts to improve patient safety.”...

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