Quickie Quiz: What's Your Adverse Events Intelligence?

Anyone who wants to get a sense of the number and type of adverse events occurring in hospitals need only look at California, where public health officials recently produced a large database of such mistakes discovered within 450 facilities.

The five-page report revealed some interesting details about the 2,446 events that came to the state's attention in the 2.5 years between July 1, 2007 and Dec. 31, 2009. These are mishaps that in all likelihood happen with similar frequency elsewhere, although perhaps with less publicity.

This is a grim topic, but since the idea in healthcare is to always learn from our mistakes, I thought it instructional to present some of the more interesting findings in the form of a multiple choice quiz.

As of July 1, 2007, California law requires hospitals to report these events to public health officials within five days of the date the incidents are discovered, and within one day if the situation represents an emergent threat to the safety of a patient, visitor or personnel. The law seems to be working.

For the first 12 months, the number of reports was 937 but in the second year, the number of reports filed was 1,509.

Also, state law that took effect in 2007 penalizes hospitals up to $100 for every day that a reportable event goes unreported. So far, recalcitrant or forgetful facilities have been assessed 260 fines totaling nearly $1.1 million for such lapses. That may make hospital compliance more likely, and these statistics more reliable.

So here goes. No cheating! Answers can be found here.

1. Of 2,446 adverse hospital events reported to California officials, 506 involved surgery. What percent of the 506 involved the retention of a foreign object, such as a sponge or a surgical tool?

a) 25%
b) 50%
c) 70%
d) 85%

2. Of the remaining surgical mistakes, which among these four was the most common?

a) Surgery performed on wrong body part.
b) Surgery performed on wrong patient.
c) Wrong surgical procedure performed on patient.
d) Death during surgery or up to 24 hours after induction of anesthesia after surgery.

3. Of the 2,446 adverse events, a patient acquired a stage 3 or stage 4 pressure ulcer after admission in what percentage?

a) 65%
b) 50%
c) 35%
d) 20%

4. Crimes that are considered adverse events in a hospital were a relatively small percentage, and only 56 were reported during these 30 months. But one type of criminal event stands out. What was it?

a) Care ordered or provided by someone impersonating a licensed health provider.
b) Abduction of a patient of any age.
c) Sexual assault on a patient.
d) Death or significant injury of a patient or staff member resulting from a physical assault.

5. Environmental events are another worrisome category of hospital mishaps that cause death or serious disability to patients. Which of these sentences about environmental adverse events is true?

a) Falls were not the biggest cause of patient death due to an environmental event.
b) Use of restraints or bedrails commonly led to death or serious disability.
c) Death or serious disability associated with a burn acquired in the hospital occurred fewer than 10 times.
d) Electric shock caused by hospital equipment was among the most common causes of serious death or disability due to environmental mistakes.

6. Of all the instances that resulted in death or serious disability involving failure of a hospital to protect patients, most of them, 80%, involved a patient attempting or committing suicide. This statement is

a) True
b) False

7. What percentage of the 2,446 adverse events resulted in death or serious disability to a patient because of a medication error?

a) 2%
b) 25%
c) 50%
d) 70%

8. California divides adverse events into two categories in terms of urgency. In the first, the incident is so serious that a patient is put in imminent danger of death or serious bodily harm. State officials are required to conduct an inspection of these more serious types of events within 48 hours of report. Of the 2,446 adverse events, how many fell into this urgent category?

a) 20%
b) 10%
c) 7%
d) 1%

9. There were how many infants discharged to the wrong person?

a) 0
b) 3
c) 10
d) 30

10. State health officials report a wide variety of surgical objects inadvertently left inside patients, – catheters, a denture, drill bits, electrodes, sponges, screws, tubing, tissue specimens, and wires – and are trying to find ways to prevent such incidents, which frequently require second surgeries to retrieve. What is California doing about the issue?

a) Requiring all foreign objects be coded in colors that contrast with human blood and tissue.
b) Requesting that $800,000 of the $5 million assessed hospitals in fines so far be spent on a study to find ways to prevent forgotten foreign surgical objects.
c) Requiring that each piece of material that could be inserted in a body cavity during surgery be equipped with a special tag detectable by electronic equipment at the surgical suite door, which would set off a signal if the patient leaves with a foreign object inside.
d) Setting up a website that publicly discloses each hospital's track record in number and type of retained foreign objects for consumers and payers to observe and compare.

Did you get stumped? Click here for the answers to find out how you scored.

I hope you learned something unexpected from this quiz, which I think may represent the largest database of its type in any state. I know that I did.