How Safe Are Hospitalized Patients?

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Three years of Medicare data was used to identify the current status of patient safety in American hospitals.

The Institute of Medicine released a landmine study in approximately 2000; countless errors were occurring in hospitals which were leading to patient deaths. Since then, the accrediting body of hospitals has joined forces with others to establish standards of patient safety which hospitals must meet, or risk being placed on a non-accredited status (with all the associated reduction in monies as a consequence). So, one could reasonably expect that safety has improved. Not so!

The following findings are eye-openers and strongly suggest that we have not arrived at a point where we can have confidence in our health care system to deliver safe care.

• Out of 40 million hospitalizations, 1.6 million errors occurred. This represents almost a 5% error rate, and a 3% increase over prior years.
• The areas which fared the worse were rate of pressure sores, failure to rescue, and post-operative respiratory failure. NOTE: Failure to rescue, while remaining among the highest safety incidents, actually has improved since the last report period.
• Pressure sores, and post-operative respiratory failure, which remain in the top 3 areas of patient safety risk, have actually become worse since the last reporting period, by 10 and 20% respectively.
• Almost 80% of the errors which resulted in deaths were preventable. It is estimated the one of four Medicare patients who had at least one patient safety incident, would die as a result.

The 16 indicators which were reviewed were:

• Total deaths among patients whose death was not expected as a result of the diagnosis.
• Pressure ulcers
• Foreign body left after surgery or a procedure
• Collapsed lungs while in hospital
• Post operative respiratory failure
• Post operative metabolic disorders which did not exist prior to surgery
• Post operative wounds which opened
• Infections due to medical care
• Complications of anesthesia
• Accidental punctures
• Post operative hemorrhages
• Post operative hip fractures
• Post operative blood clots of serious consequences; i.e. deep vein thrombosis or lung clots
• Post operative sepsis (or overwhelming blood infection)
• Transfusion reaction
• Failure to rescue

The last indicator, failure to rescue, deserves special attention. Of all the indicators specified, failure to rescue probably has the highest likelihood to be related to the number of RN’s available to the patient. All other indicators may be related to many other variables, such as the patient’s age, compliance with treatment plan, complexity of care, etc. Failure to rescue is defined as the patient’s condition deteriorating and an RN either not being available, or if available, not reporting or intervening in the patient’s situation.

As always, quality of care is associated with the cost of care, and in this case, billions of dollars were expended as a result of preventable errors. Additionally, medication errors, which also have a high error rate and potentially lead to death, were not included in this ‘look-see’ of patient safety.

The good news is that some hospitals are beginning to turn the corner, and proving that needless errors can be eliminated. These hospitals are identified in the references listed and should be applauded by the general public. They are working for you!

Journal of Nursing Administration, 2006
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16404195

Failure to Rescue: Needless Deaths are Prime Examples of the Need for More Nurses at the Bedside; Robert Wood Foundation, 2003
http://www.rwjf.org/research/researchdetail.jsp?id=1752&ia=137

Health Grade Quality Study
4th Annual Patient Safety American Hospitals Study, April, 2007
http://www.healthgrades.com/media/dms/pdf/PatientSafetyInAmericanHospitalsStudy2007.pdf