AHRQ: Rate of Adverse Events in Medicare Cases 'Disturbing'

One in seven Medicare beneficiaries suffers an adverse event during a hospital stay, and those events, nearly half of them preventable, contributed to at least 15,000 deaths in a single month, a federal study has found.

The adverse events included the National Quality Forum Serious Reportable Events; Medicare hospital-acquired conditions; and events resulting in prolonged hospital stays, permanent harm, life-sustaining intervention, or death.

The incidence rate projects to about 134,000 Medicare beneficiaries—13.5%—experiencing at least one adverse event in hospitals during a single month, with events contributing to the deaths of about 15,000 beneficiaries, according to the audit by the Department of Health and Human Services' Office of Inspector General. 

Physician reviewers for OIG determined that 44% of adverse events were preventable, most commonly because of medical errors, substandard care, and inadequate patient monitoring. Additional hospital care necessitated by these events consumed an estimated 3.5% of Medicare's inpatient expenditures for the sample month—about $4.4 billion in Medicare costs annually. Two-thirds of these costs were the result of additional hospital stays, the study found. 

OIG recommended that the Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services lead national efforts to reduce events, broaden patient safety efforts to include all types of adverse events, and enhance efforts to identify events. OIG wants CMS to provide more incentives for hospitals to reduce adverse events through its payment and oversight functions, including strengthening the Medicare hospital-acquired conditions policy, and holding hospitals accountable for adopting evidence-based practices.

In a letter to HHS Inspector General Daniel R. Levinson, CMS Administrator Donald Berwick, MD, said the report demands that "solutions need to be addressed as quickly and as efficiently as possible." Berwick said CMS has taken action on some of the issues but "more work needs to be done," and that CMS would play a more proactive role in providing "a culture of safety across the country in all healthcare settings."

"While the report characterizes CMS as an oversight entity and the nation's largest health payer, CMS is also actively transitioning from serving solely as a regulator and passive payer of healthcare services to an agency that fully supports public health goals as an active payer of high quality and efficient care," Berwick said.

AHRQ Director Carolyn M. Clancy, MD, told Levinson she agreed with the findings, which she called "consistent with previous studies, but are nonetheless disturbing. They confirm that adverse events continue to affect hospital patients at an alarming rate and that the types of events that occur vary widely."

Clancy said the report "reaffirms AHRQ's need to continue to work on improving patient safety by broadening investigations to include areas that are not always seen on lists of adverse events that should never occur or should always be reported."

Clancy said AHRQ intends to foster continued improvement in both identifying and reducing adverse events through operational programs, research efforts, and further collaboration with other agencies.

The American Hospital Association issued these remarks Tuesday, "While hospitals have made great strides in improving care, this report highlights that there is more we can do. Hospitals are already engaged in important projects designed to improve patient care in many of the areas mentioned in the report. We are committed to taking additional needed steps to improve patient care. That is why we support the report's recommendations for further research to improve our understanding of what caused the error and how to prevent it from happening again.

The OIG report is based on a national sample of 780 Medicare beneficiaries discharged from acute care hospitals in October 2008. Physician reviewers used medical records to identify adverse events and assess whether each event was preventable. OIG used Medicare claims data to estimate Medicare costs.