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1 in 3 Hospitalized Patients Suffers an Adverse Event

 |  By cclark@healthleadersmedia.com  
   April 07, 2011

Just when you thought you and your fellow providers have made hospitals safer, the April edition of the journal Health Affairs publishes a series of reports that might change your mind.

At least a dozen separate reports in the quality- themed issue focus on how bad the system still is, and how much it needs to improve. Worse, as at least one study emphasizes, healthcare providers in large part are unaware how many harmful errors they still make.

In one report, researchers who studied three methods to detect serious adverse events conclude that the commonly used method of voluntary reporting and the Agency for Healthcare Research and Quality's Patient Safety Indicators capture only one-tenth of these flaws in care.

On the other hand, a newer tool developed by the Institute for Healthcare Improvement, called the Global Trigger Tool, now used by only 2% of hospitals in the U.S., caught all 10.

Specifically, the GTT detected 354 adverse events, while the AHRQ system, used by roughly half the hospitals in the U.S., found only 35 and the voluntary method found just four, according to the authors. These adverse events include medication errors, procedural errors and hospital-acquired infections, pulmonary venous thromboembolisms, pressure ulcers, device failures and patient falls.

"Overall, adverse events occurred in 33.2% of hospital admissions (range: 29% to 36%) or 91 events per 1,000 patient days," says the lead author, David Classen, MD, associate professor of medicine at the University of Utah in Salt Lake City.

Imagine telling a hospital patient on admission that they have a one in three risk of suffering some harm from an error unrelated to the condition or disease that brought them there. It's almost enough to make you forget about accountable care organizations, or that there ever was talk about bending the cost curve.

It's almost enough to make patients stay away from hospitals altogether.

Classen's numbers are even worse than those released last November by the U.S. Office of Inspector General, which said 13.5% of hospitalized Medicare beneficiaries experienced one or more adverse events during their stay, according to a sample of all Medicare discharges in October, 2008. "An estimated 1.5% experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month," the report said.

Classen tells me that the GTT isn't used in part because hospitals don't know about it, – it's still very new – but also because it's expensive. To use the GTT tool meaningfully requires at least one senior clinical, highly trained professional (at a cost of about $100 an hour) to spend about 150 hours going through a representative sample of about 10% of a typical hospital's 3,000 discharge charts each month.

Also, he says, many hospitals think that the way they're currently tracking adverse events does the job quite adequately.

"It's a learning curve that a lot of places still have to go through," he says.

What's even more worrisome is that Classen says the hospitals selected for this study are already ahead of the curve. They already had extensive patient safety programs and are much further along in their patient safety and adverse event detection journey than other hospitals.

So there are 10 times more harmful medical errors than we knew about, even at the best hospitals.

As if that paper isn't enough to make you worry anew about the quality chasm, another article in the April edition of Health Affairs, by Jill Van Den Bos and colleagues at Milliman's Denver Health practice, estimates the number of hospital adverse events or medical errors resulting in death, is really double what was estimated by the Institute of Medicine's 1999 report, "To Err Is Human" or 44,000 to 98,000 a year.

More realistically, her report estimates there are 187,000 hospital deaths a year. And other than the IoM report's estimate of one million injuries, in fact, the Milliman study says there are 6.1 medically-caused injuries inside and outside hospitals.

And another article, by John Goodman, chief executive officer of the National Center for Policy Analysis in Dallas, estimates enormous social costs– $393 billion to $958 billion per year due to adverse medical events.

A fourth article looked just at California acute care hospitals and estimated that 9,600 Californians die from hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)infections each year. Those infections add $3 billion to the state's healthcare costs annually. Although California now has a public reporting program geared to raising awareness and reducing such errors, many other states do not.

Indeed, hospital reporting in California is revealing the extent of the problem. A recent table prepared by the California Department of Public Health reveals an increase in reporting in each of the last three fiscal years in all categories of adverse events. For example, surgical events increased from 224 in FY 2007/08 to 273 in FY 2008/09 to 344 in FY 2009/10. 

Retention of a foreign surgical object, the biggest share of those, increased from 154 to 191 to 266.

Care management events increased from 616 to 1023, but dropped slightly to 1,004. These include deaths or serious disabilities associated with a medication error, incompatible blood, labor and delivery, hypoglycemia, hyperbilirubinemia in neonates, decubitus ulcers or spinal manipulation therapy. I hope they are not making more errors, but are in fact just reporting many that were silently hidden in the past.

We want to know that providers have shifted to more careful culture, especially prompted by the threat of federal penalties and value-based incentives set forth in the Patient Protection and Affordable Care Act.

But we also want to know that they are looking as hard as they can to see these errors where they are. Only then can they be quantified, taken more seriously and prevented.

Lest we get too complacent, we have to realize that avoidable mistakes that cause patient harm are still being made. The current issue of Health Affairs points that out in graphic detail.

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