Table 4.
Severity and Preventability of Hospital-Acquired Adverse Events (AEs) Identified Using the Global Trigger Tool across the Eight Baylor Health Care System Acute Care Hospitals by AE Category (January 2008–December 2011*)
| Severity† | Preventability‡ | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| AE Category | Total | E | F | G | H | I | Yes | Probably | Possibly | No | Cannot Tell |
| Surgical/procedural AE | 676 | 402 | 228 | 7 | 36 | 3 | 4 | 11 | 490 | 169 | 2 |
| Medication AE | 435 | 312 | 85 | 1 | 34 | 3 | 5 | 13 | 174 | 242 | 1 |
| Infection | 212 | 114 | 82 | 0 | 10 | 6 | 2 | 84 | 119 | 7 | 0 |
| IV related | 70 | 70 | 0 | 0 | 0 | 0 | 0 | 2 | 67 | 1 | 0 |
| Fluid overload/pulmonary edema | 51 | 23 | 22 | 0 | 6 | 0 | 1 | 9 | 41 | 0 | 0 |
| Perinatal AE | 45 | 33 | 11 | 0 | 1 | 0 | 0 | 11 | 29 | 5 | 0 |
| Thrombosis/Embolism | 41 | 17 | 24 | 0 | 0 | 0 | 1 | 4 | 17 | 19 | 0 |
| Sepsis | 41 | 7 | 20 | 0 | 4 | 10 | 0 | 23 | 16 | 2 | 0 |
| Pressure ulcer | 26 | 25 | 1 | 0 | 0 | 0 | 0 | 25 | 1 | 0 | 0 |
| Fall with injury | 10 | 7 | 2 | 1 | 0 | 0 | 0 | 0 | 9 | 1 | 0 |
| Blood transfusion reaction | 9 | 7 | 1 | 0 | 1 | 0 | 0 | 0 | 2 | 7 | 0 |
| Pneumothorax | 9 | 1 | 7 | 0 | 1 | 0 | 0 | 0 | 9 | 0 | 0 |
| Stroke | 7 | 0 | 4 | 3 | 0 | 0 | 0 | 0 | 3 | 4 | 0 |
| Other AE | 37 | 22 | 10 | 1 | 4 | 0 | 0 | 4 | 21 | 9 | 3 |
| Total | 1,669 | 1,040 | 497 | 13 | 97 | 22 | 13 | 186 | 998 | 466 | 6 |
January–December 2007 data were excluded as the list of categories was still under development.
NCC MERP classifications: E = temporary harm that required intervention; F = temporary harm that required initial or prolonged hospitalization; G = permanent harm; H = intervention required to sustain life; I = death.
Based on the reviewer’s clinical knowledge, he/she feels the AE was as follows: definitely preventable (Preventable); more likely than not the AE could have been prevented (Probably Preventable); there is some chance the AE could have been prevented (Possibly Preventable); the event was definitely not preventable (Not Preventable); not able to be assigned to any of the categories of preventability (Unable to Determine).