The process of finding adverse care events is called surveillance, and there are different approaches, not all created equal. Even those charged with overseeing patient safety say Utah's surveillance system is anemic.

Utah needs to improve ongoing surveillance, boost identification of patient-safety events and come up with statewide interventions to improve whole systems of care, says Iona Thraen, patient safety pointwoman for the Utah Department of Health.

Public health officials say that would take two staffers and $250,000 in program funding to do jobs like data input and analysis, trend assessment, report writing and creation, and then evaluation of interventions.

The budget is so pinched that Thraen's own role as patient safety manager is a part-time position. Lawmakers turned down a request last session for a full-time safety person.

So Utah makes do.

When it comes to surveillance, one of the most common but least reliable approaches is voluntary reporting — the very heart of Utah's patient safety system. That, says Michael Silver of HealthInsight, captures things that can't be hidden, like removing the wrong limb.

Chart review is another surveillance tool. Medical charts are examined, well after the patient has been discharged or died, to see if anything indicates an untoward medical event during the course of care. The Utah Department of Health does that on a limited basis. But neither that nor voluntary reporting offers immediate intervention for the patient who may be suffering harm, laments Thraen, who adds that better systems cost money that the department doesn't have.

The third, and increasingly popular, method of surveillance started in Utah when an informatics whiz at LDS Hospital, Scott Evans, wondered what could be found if they simply looked for antidotes. He programmed the electronic medical records system to watch for "triggers" — someone ordering an antibiotic that's not a routine part of the patient's treatment or a lab test to check for infection, for example.

The power of clinical triggers was impressed on Dr. Brent James, nationally recognized authority on patient safety, when his dad was hospitalized with congestive heart failure in 1998. The senior James had trouble breathing, and fluid packed his lungs. His heart wasn't pumping his blood out fast enough, and he was swollen and gray. His oxygen saturation level was below 80, "borderline dead," James remembers.

He was hospitalized overnight, placed on oxygen and given a diuretic called Lasix to remove the excess fluid — all standard care. The fluid drained off, he could breathe better and his oxygen level vastly improved. But he woke in severe pain, with life-threatening inflammation of his pancreas.