A recent report by HHS’s
inspector general revealed that adverse events are more prevalent and more
costly than anticipated. One in seven
Medicare patients will suffer serious harm from medical care, which equals about
134,000 in a month 1.6 million over a year, and about 180,000 deaths. Even greater numbers are related to harm that
required medical intervention but was not as serious, and approximately 13.1%
had an adverse event resulting in temporary harm. Hospital care associated with adverse and
temporary harm events cost Medicare paid approximately $324 million a month,
and around $4.4 billion annually for that related treatment. About 44% of these adverse events were
preventable errors. Two-thirds of the
additional costs were associated with the additional hospital stays, but the
calculations did not include the costs related to follow up care.
The majority of
preventable events were linked to medical errors, substandard care and lack of
patient monitoring and assessment.
Common events included:
|
Types of Adverse Events
|
Number of Events and %s of Total Events
|
|
Events Related to Medication
|
31% (40)
|
|
Excessive bleeding
|
12
|
|
Delirium or change in mental status
|
7
|
|
Hypoglycemic event
|
6
|
|
Acute renal insufficiency (kidney
failure)
|
4
|
|
Severe hypotension
|
4
|
|
Respiratory complications
|
4
|
|
Severe allergic reactions
|
3
|
|
Events Related to Patient Care
|
28% (36)
|
|
Intravenous volume overload
|
10
|
|
Aspiration
|
8
|
|
Deep vein thrombosis or pulmonary embolism
|
5
|
|
Exacerbation of preexisting medical
condition
|
5
|
|
Stage III pressure ulcer
|
3
|
|
Breakdown of surgical wound
|
1
|
|
Congestive heart failure
|
1
|
|
Hypoxia (oxygen deficiency)
|
1
|
|
Patient fall with injury
|
1
|
|
Prolonged weakness and dizziness
|
1
|
|
Events Related to Surgery or Other Procedures
|
25% (33)
|
|
Excessive bleeding
|
5
|
|
Severe hypotension
|
4
|
|
Respiratory complication
|
4
|
|
Iatrogenic pneumothorax
|
3
|
|
Postoperative ileus
|
3
|
|
Postoperative urinary retention
|
3
|
|
Acute coronary syndrome
|
2
|
|
Blood clot and other occlusion
|
2
|
|
Cardiac complication
|
2
|
|
Cardiac dysrhythmia
|
1
|
|
Delay in surgery because of equipment
malfunction
|
1
|
|
Hemorrhage at surgical site
|
1
|
|
Seroma (fluid) following stomach
resection
|
1
|
|
Urinary catheter-associated trauma
|
1
|
|
Events Related to
Infection
|
15% (10)
|
|
Urinary tract infection
|
5
|
|
Vascular catheter-associated infection
(central or peripheral line)
|
4
|
|
Other bloodstream infection
|
4
|
|
Respiratory infection
|
4
|
|
Surgical or procedural site infection
|
2
|
There were similar
findings for temporary harm issues:
|
Types of Temporary Harm Events
|
|
|
Events Related to Medication
|
42% (73)
|
|
Delirium or change in mental status
|
22
|
|
Hypoglycemic event
|
11
|
|
Thrush and other opportunistic
infection
|
7
|
|
Allergic reaction or side effect related to
skin
|
6
|
|
Gastrointestinal complication
|
5
|
|
Hypotension
|
5
|
|
Dysrhythmia
|
3
|
|
Excessive bleeding
|
3
|
|
Severe headache or dizziness
|
3
|
|
Acute renal failure or insufficiency
|
2
|
|
Allergic reaction to blood or related
products
|
2
|
|
Respiratory complication
|
2
|
|
Other events related to medication
|
2
|
|
Events Related to Patient Care
|
36% (63)
|
|
Stage I, Stage II, or unstaged pressure
ulcer
|
20
|
|
Intravenous volume overload
|
15
|
|
Skin tear, laceration, abrasion, or other
breakdown
|
9
|
|
Intravenous infiltrate with symptoms
|
6
|
|
Patient fall with injury
|
5
|
|
Aspiration
|
3
|
|
Failure to treat constipation or
obstipation
|
3
|
|
Tachycardia or dysrhythmia
|
2
|
|
Events Related to Surgery or Other Procedures
|
18% (32)
|
|
Urinary retention
|
8
|
|
Excessive bleeding
|
6
|
|
Cardiac complication
|
4
|
|
Surgical tear or laceration
|
3
|
|
Urinary catheter-related trauma
|
3
|
|
Prolonged nausea and vomiting
|
2
|
|
Postoperative or postprocedural
hypotension
|
2
|
|
Respiratory complication
|
2
|
|
Other events related to surgery or other
procedures
|
2
|
|
Events Related to
Infection
|
4% (6)
|
|
Surgical site infection
|
2
|
|
Bacterial infection
|
1
|
|
Respiratory infection
|
1
|
|
Urinary tract infection
|
1
|
|
Vascular catheter-associated infection
|
1
|
Source: OIG analysis of hospital stays for 780 Medicare beneficiaries
in October 2008
Nearly all the events
listed in the NQF adverse events and the HACs were considered preventable. As a result of these findings. CMS is further
dedicated to broadening patient safety efforts and to expand them beyond the
CMS HACs. The study looked at
preventable adverse events and only .6% of the adverse events would have been
on the NQF list and1% would qualify as a HAC, and CMS responded that it would
“aggressively pursue” efforts to expand adverse event reporting to include more
types of events. Therefore, the OIG
tasked CMS with expanding its list of HACs and to hold hospitals accountable
for the adoption of evidence-based guidelines.
Product lines that could reduce
these adverse or preventable events should partner with their customers to
address these issues before financial penalties or disincentives become
attached to their occurrence. SMT can
help you understand the opportunities and help you develop the message to
promote patient safety in light of these forthcoming anticipated reforms.
Office of Inspector
General Adverse Events in Hospitals: National Incidence Among Medicare
Beneficiaries http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf
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