Utah's patient safety surveillance system called anemic

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.

As James and his dad's doctor were trying to figure things out, the lead pharmacist walked in, unsummoned, "to treat Mr. James' Lasix allergy." Lab tests showed an elevated amylase level, and because it was one of the system's triggers, he was notified. He came to fix the problem almost before the others knew they had one and certainly before they knew what it was.

Over the years, they've developed and fine-tuned more triggers, James says. "We just started to correct everything we found, not getting too uptight. Most are not errors, and we don't know how to prevent them." As they simply handled things that came up, "we came to appreciate the value of clever people with good data."

It's not enough to expect facilities to spot and report what happens, James says. For one thing, much of what happens that shouldn't or that could harm a patient is never recognized. James points to Great Britain, which made a "totally safe voluntary reporting system" and was collecting information on 12,000 events a month. When they ran tools like triggers and chart reviews, they found they had still missed nine out of 10 medical-harm events with the self-reports.

Best of all, he says, clinical trigger response is in near real-time, not a look into the past. So it changes the future for patients. The current surveillance system also relies on administrative claims data, which Thraen says "has a lot of error and extrapolation." It, too, is a look back.

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E-mail: lois@desnews.com