Scope of the Problem

More than two decades ago, the Institute of Medicine published To Err is Human: Building a Safer Health System in 2000.  The report focused America's attention on the preventable harm and 98,000 deaths caused by medical errors in our hospitals every year.

It took six years, but the U.S. Congress was moved to enact the The Tax Relief and Health Care Act of 2006.  It mandated the Office of Inspector General (OIG) to prepare a report to Congress regarding the incidence of Never events among Medicare beneficiaries, the payment for services in connection with such events, and the Centers for Medicare & Medicaid Services (CMS) processes to identify events and deny payment.

The U.S. Department of Health and Human Services, Office of Inspector General (OIG) has been tracking and reporting adverse events in hospitals and other health care settings since 2006. These adverse event studies used an adapted Global Trigger Tool (GTT) designed by the Institute for Healthcare Improvement (IHI), to capture all causes of harm, as well as the preventability of patient harm events.

• The OIG released the first Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, in 2010. The 2010 study, randomly selected 785 Medicare Beneficiaries from the 999,645 beneficiaries discharged from acute care hospitals during October 2008. Five (5) beneficiaries were excluded because the hospital was currently under OIG investigation, resulting in a sample of 780 beneficiaries. The review was a two stage process:
  • In the first stage the OIG contracted certified International Classification of Diseases (ICD) coders and registered nurses to conduct a preliminary review of the sample medicare records from October, 2008.
    • Certified coders reviewed the 780 records for International Classification of Diseases (ICD) codes that were not present on admission.
    • Nurse reviewers used a modified version of the IHI GTT protocol, to identify triggers in the medical records possibly indicative of adverse events.
    • The records were also reviewed for readmissions within thirty (30) days of initial October 2008 discharge. The 780 initial records were reduced to 420 records for second stage review.
  • The second stage involved physician review of the 420 cases that met the requirements of stage one.  The physicians counted an adverse event when the patients experienced harm during a hospital stay or during prior, contiguous outpatient visits (wherein patients were transferred directly from outpatient care to inpatient care within the same facility). Physician reviewers also determined the extent to which the identified events were preventable.

  The OIG provided a comparison of findings from the first nationwide estimate of patient harm (2008) with the second national estimate of patient harm from 2018, This report was released in 2022.

Additional studies

• A systematic, meta-analysis of 16 studies of preventable inpatient deaths by Rodwin, B. et al. was published in the 2020 Journal of General Internal Medicine, puts the number of preventable deaths at just over 22,000 a year in the United States. However, of the 23,524 inpatient deaths from 16 included studies, only 515 occurred in US hospitals, and a significant portion of those deaths were from data collected before 1988 or from special population facilities i.e. VA hospitals. In addition,  under-reporting was not assessed. This study may not be representative of the US inpatient experience.
• HealthGrades, Inc. provides several valuable consumer services, including an annual patient safety report card for the healthcare industry. A HealthGrades study of the period 2018- 2020, 170,231 potentially preventable patient safety events occurred among Medicare patients in U.S. hospitals. Healthgrades found that just four patient safety indicators accounted for 74% of all reported patient safety events: hip fracture due to an in-hospital fall, collapsed lung resulting from a procedure/surgery, pressure or bed sores acquired in-hospital, and catheter-related bloodstream infections acquired in-hospital.
• Healthgrades also found that patients treated in hospitals receiving the Healthgrades 2022 Patient Safety Excellence Award™ were, on average:
  • 55.8% less likely to experience an in-hospital fall resulting in hip fracture, than patients treated at non-recipient hospitals.
  • 52.6% less likely to experience a collapsed lung resulting from a procedure or surgery in or around the chest, than patients treated at non-recipient hospitals.
  • 66.2% less likely to experience pressure sores or bed sores acquired in the hospital, than patients treated at non-recipient hospitals.
  • 65.8% less likely to experience catheter-related bloodstream infections acquired in the hospital, than patients treated at nonrecipient hospitals.
  • If all hospitals as a group performed similarly to the Healthgrades Patient Safety Award Recipients, 100,189 patient safety events could have been avoided during the study period.
• The 2023, Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions funded retrospective study by Bates et al., of adverse events in a random sample of 2809 admissions to 11 Massachusetts hospitals during 2018 found:
  • At least one adverse event occurred in 23.6% of the random admissions
  • Of the 978 adverse events 22.7% were determined to be preventable and 32% were deemed serious.
  • A preventable adverse event occurred in 191 (6.8%) of all admissions.
    • Adverse drug events accounting for 39.0% of all events,
    • Surgical or other procedural events (30.4%),
    • patient-care events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care–associated infections (11.9%).

Nursing provides the vast majority of direct patient care. Whether it is transmission of nosocomial infection, medication error, wrong-site surgery, failure to protect, etc.; nursing was probably involved at some point. Nursing must act to establish safe patient care as its singular purpose.

References

Bates, D. W., Levine, D. M., Salmasian, H., Syrowatka, A., Shahian, D. M., Lipsitz, S., Zebrowski, J. P., Myers, L. C., Logan, M. S., Roy, C. G., Iannaccone, C., Frits, M. L., Volk, L. A., Dulgarian, S., Amato, M. G., Edrees, H. H., Sato, L., Folcarelli, P., Einbinder, J. S., … Mort, E. (2023). The safety of inpatient health care. New England Journal of Medicine, 388(2), 142–153. https://doi.org/10.1056/nejmsa2206117

Healthgrades Patient Safety 2022 Infographic. https://www.healthgrades.com/quality/patient-safety-2022-infographic.

Office of Inspector General | Government oversight | U.S. Department of Health and Human Services. (2010). Adverse events in hospitals: National incidence among Medicare beneficiaries. Retrieved April 4, 2023, from https://www.oig.hhs.gov/oei/reports/oei-06-09-00090.pdf

Adverse events in hospitals: A quarter of Medicare patients experienced harm in October 2018. (2022). Oversight.gov. Retrieved April 8, 2023, from https://www.oversight.gov/report/HHSOIG/Adverse-Events-Hospitals-Quarter-Medicare-Patients-Experienced-Harm-October-2018

Rodwin, B. A., Bilan, V. P., Merchant, N. B., & Gupta, K. (2020). Rate of preventable mortality in hospitalized patients: A systematic review and meta-analysis. Journal of General Internal Medicine, 35(7), 2099-2106. https://doi.org/10.1007/s11606-019-05592-5

Tariq, R. A., Vashisht, R., Sinha, A., & Sproat, T. (2023). Medication dispensing errors and prevention. In StatPearls. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519065/

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