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Stanford Report, March 19, 2003

Tool helps analyze medical errors

The Stanford-UCSF Evidence-based Practice Center, a collaborative effort that analyzes scientific evidence to improve health-care quality, has developed a statistical software tool that can help health-care professionals identify patterns and trends in 26 types of preventable medical errors and complications.

By performing statistical analyses on discharge data routinely gathered by hospitals, the Patient Safety Indicators tool can highlight potential medical errors that have recently occurred, said Kathy McDonald, associate director of the practice center. Hospitals can then investigate to determine whether the problems detected were caused by preventable medical errors or have some other explanation.

Such analysis can highlight processes that hospitals should consider revamping in order to prevent problems. The 26 adverse events tracked by the tool include fractures following surgery, reactions to a blood transfusion, bedsores, sepsis infections and objects inadvertently left in the body after surgery.

Health and Human Services Secretary Tommy G. Thompson announced the Patient Safety Indicators last week at the National Patient Safety Foundation’s 5th Annual Congress in Washington, D.C.

The tool can be downloaded for free from AHRQ’s Web site at www.qualityindicators.ahrq.gov, but it requires the use of commercially available specialized software.