Patient-safety incidents: 10% died

Health Grades, Inc.Apr 1 2010

Nearly one million patient-safety incidents occurred among Medicare patients over the years 2006, 2007, 2008, a figure virtually unchanged since last year's annual study of patient safety by HealthGrades, the leading independent healthcare ratings organization. In all, the incidents were associated with $8.9 billion in costs. One in ten patients -- 99,180 individuals -- experiencing a patient-safety incident died as a result, the study found.

The seventh annual HealthGrades Patient Safety in American Hospitals study, which evaluated 39.5 million hospitalization records from the nation's nearly 5,000 nonfederal hospitals using indicators developed by the federal Agency for Healthcare Research and Quality, tracks trends in a range of patient safety incidents and identifies those hospitals that are in the top 5% in the nation.

Patients at hospitals in the top 5% -- 2010 HealthGrades Patient Safety Excellence Award™ recipients -- experienced 43% fewer patient safety incidents, on average, compared to poorly performing hospitals. If all hospitals performed at this level, 218,572 patient safety incidents and 22,590 deaths could potentially have been avoided, saving $2.0 billion from 2006 through 2008.

The list of award recipients, and the patient-safety ratings of all nonfederal hospitals, can be viewed for free at HealthGrades.com. Thirty-nine states have at least one award recipient.

"This annual study serves the twin goals of documenting the state of patient safety for hospitals to benchmark against, and providing individuals with objective information with which to evaluate local hospitals," said Rick May, MD, a vice president at HealthGrades and co-author of the study. "It is disheartening, however, to see that the numbers have not changed since last year's study and, in fact, certain patient safety incidents, such as post-operative sepsis, are on the rise."

Study highlights:

Large Safety Gaps Identified Between Top and Bottom Performing Hospitals
•Patients treated at top-performing hospitals had, on average, a 43% lower chance of experiencing one or more medical errors compared to the poorest-performing hospitals.

Patient safety events are common at U.S. hospitals
•Between 2006 and 2008 there were 958,202 total patient safety events among Medicare beneficiaries, representing 2.29% of the 39.5 million Medicare admissions.

Common Patient Safety Events are Very Costly
•Between 2006 and 2008 these patient safety events were associated with over $8.9 billion in excess costs.

Less Improvement Seen Among Most Common Events
•Six patient safety indicators showed improvement while eight indicators worsened in 2008 compared to 2006. Some of the most common and most serious indicators worsened, accounting for 78.94% of the total patient safety incidents studied. These include decubitus ulcer (bed sores), iatrogenic pneumothorax (collapsed lung), post-operative hip fracture, post-operative physiologic and metabolic derangements, post-operative pulmonary embolism (potentially fatal blood clots forming in the lungs) or deep vein thrombosis (blood clots in the legs), post-operative sepsis, and transfusion reaction.

Approximately One in Ten Medicare Patients with Patient Safety Events Died
•Between 2006 and 2008 there were 99,180 actual inhospital deaths that occurred among patients who experienced one or more of the 15 patient safety events.

Most Common Patient Safety Incidents
•The patient safety incidents with the highest incidence rates are, along with the event rates per 1,000: failure to rescue (92.71), decubitus ulcer (36.05), post-operative respiratory failure (17.52) and post-operative sepsis (16.53).

Methodology
The seventh annual HealthGrades Patient Safety in American Hospitals Study applies methodology developed by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) to identify the incident rates of 15 patient safety indicators among Medicare patients at virtually all of the nation's nearly 5,000 nonfederal hospitals. Additionally, HealthGrades applied its methodology using 12 patient safety indicators to identify the best-performing hospitals, or HealthGrades Patient Safety Excellence Award™ Hospitals, which represent the top five percent of all U.S. hospitals.

The following are the 15 patient safety indicators studied:

•Complications of anesthesia
•Death in low mortality Diagnostic Related Groupings (DRGs)
•Decubitus ulcer (bed sores)
•Death among surgical inpatients with serious treatable complications
•Iatrogenic pneumothorax
•Selected infections due to medical care
•Post-operative hip fracture
•Post-operative hemorrhage or hematoma
•Post-operative physiologic and metabolic derangements
•Post-operative respiratory failure
•Post-operative pulmonary embolism or deep vein thrombosis
•Post-operative sepsis
•Post-operative abdominal wound dehiscence
•Accidental puncture or laceration
•Transfusion reaction

Complete methodology can be found in the study, available at http://www.healthgrades.com.