Patient Safety Incidents Showed Little Change in 2009, Says HealthGrades

Janice Simmons, March 31, 2010

While the number of patient safety incidents that occurred among hospitalized Medicare patients dipped slightly below the one million mark in 2009, the number of injured did not vary greatly from the rates in previous years, according to the new annual study from HealthGrades, an independent healthcare ratings organization based in Golden, CO.

Overall, the incidents created additional health costs of $8.9 billion annually. Also, 99,180 Medicare patients—a tenth of those who had experienced a patient safety incident—died as a result, according to HealthGrades' Patient Safety in American Hospitals study that examined data from nearly 5,000 nonfederal hospitals.

HealthGrades used indicators developed by the Agency for Healthcare Research and Quality (AHRQ) and Medicare to track patient safety incidents and identify which hospitals were in the top 5% in the nation in preventing patient safety incidents.

The report found that 238 top-performing hospitals, which received HealthGrades' "2010 Patient Safety Excellence Awards," had on average 43% fewer patient safety incidents, when compared with poorly performing hospitals. If each hospital operated at the level of the top 5% hospitals, HealthGrades estimated that 218,572 patient safety incidents—and 22,590 deaths—could have been avoided between 2006 to 2008, saving another $2 billion.

The findings that some indicators were worsening, such as for post-operative sepsis, over time "weren't surprising, but they were disappointing," says Rick May, MD, a HealthGrades vice president and study coauthor.

"There's been so much emphasis over the last few years from different governmental agencies like AHRQ and [others], such as the Institute for Healthcare Improvement, on really combating a lot of these patient safety type events," he says. "It's very disappointing that there hasn't been more movement on a nationwide basis, given the amount of attention, time, effort, and resources that have been put into making hospitals better in these areas."

Best practices addressing sepsis and central line infections have been established over the past few years, May adds.

"But one of the critical problems we see nationwide is that hospitals simply don't implement them; the knowledge is there, but they do not follow through on making sure that they're implementing those best practices on every single patient every single time."

HealthGrades also found:

  • The patient safety incidents with the highest incidence rates (using the measure of event rates per 1,000 population) were failure to rescue (92.7), decubitus ulcers or bed sores (36.1), post operative respiratory failure (17.5), and post operative sepsis (16.5).
  • Eight indicators worsened over the course of the study—decubitus ulcers; iatrogenic pneumothorax; post operative hip fracture; post-operative physiologic and metabolic derangements; post operative respiratory failure; post operative pulmonary embolisms or deep vein thrombosis; post operative sepsis; and transfusion reaction. These indicators accounted for almost 78% of the total patient safety events during the study period. During the latest three year period, the post-operative sepsis incidence rate in particular jumped by 26% from 14.6 per 1,000 in 2006 to 18.4 per 1,000 in 2008.
  • Six indicators showed improvement over the course of study—complications related to anesthesia, failure to rescue, selected infections due to medical care, post operative hemorrhage or hematoma, post operative abdominal wound dehiscence, and accidental punctures or lacerations. These six indicators accounted for 20% of total patient safety events during the study period.
  • Thirty nine states had one or more hospitals recognized with a HealthGrades Patient Safety Excellence Award. The top 10 states in overall average performance were Iowa, Kansas, Minnesota, Montana, Nebraska, North Dakota, Oregon, South Dakota, Washington. and Wisconsin.
  • One-third of the 238 hospitals receiving excellence awards were located in six states—California, Florida, Indiana, Minnesota, Ohio, and Pennsylvania. Also, 111 of those hospitals were teaching hospitals and 127 were non-teaching hospitals.

Janice Simmons Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at
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