When we receive documents in the public interest, we will publish them here with consent.
In the meantime, this link will lead you to recent research that suggests that adverse events (that’s either bad luck or a cock up) in hospitals may be ten times greater than previously measured. Alas, the research is protected by pay-wall, but in a nutshell the harder you look for evidence of medical harm, the more likely you are to find it. Using something called – wait for it – a Global Trigger Tool (GTT), researchers found that adverse events occurred in a third of all hospital admissions in the US. A similar trial of the GTT in UK general practice found that a quarter of those over 75 are harmed by their care each year.
The harm is not always avoidable, and it’s not always serious – although the repeated inconvenience of even minor harm can still result in significant costs for patients, health systems and the economy. What’s most interesting is that many patients and staff are unaware that adverse events have occurred. Patients shovel in handfuls of drugs and the staff are too stressed and busy to find out if they’re doing more harm than good. It’s only when you carefully analyse the notes of patients who are at highest risk that you start noticing adverse events. If you want to ‘do no harm’ first you have to count the harm. Properly. Then put it on display where everyone can see it. Then we can all try to do something about it.