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?
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?
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.