High adverse event rate paints ‘serious’ picture of inpatient harm

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Almost one quarter of hospital patients in the U.S. experience an adverse event such as medication-related harm, a pressure injury or infection during their care, according to a new study.

The research, which looked at a random sample of 2,809 admissions from 11 Massachusetts hospitals in 2018, found that out of the adverse events, 22.7% were deemed preventable, and 32.3% were classified as serious, life-threatening, or fatal. The study was published Wednesday in the New England Journal of Medicine.

“It’s a serious, high rate of harm,” said Dr. Peter Pronovost, chief quality and clinical transformation officer at University Hospitals in Cleveland, who was not involved in the research. “What’s troubling is that we don’t seem to have a great trend, despite a couple of decades of working on this stuff.”

The findings are similar to those detailed in an Office of Inspector General patient harm report released in May. That report found one in four Medicare patients experience patient harm during short-term, acute-care hospital stays.

Though some patient safety measures like those around infection control have gradually improved, there has not been drastic improvement in outcomes since the publication of the 1991 Harvard Medical Practice Study, which raised the alarm nationwide on the topic of patient safety, Provonost said.

The current study found seven deaths were the product of harm events, one of which was labeled as preventable. Adverse drug events accounted for 39% of all events; surgical or other procedural events comprised 30.4%; patient-care events, including falls and pressure ulcers, accounted for 15%; and healthcare-associated infections were 11.9%. 

Out of all patient admissions, 6.8% experienced a preventable adverse event and 1% experienced a preventable adverse event with a severity level of serious or higher, researchers found.

The study was funded by a grant from the Controlled Risk Insurance Company of Vermont and the Risk Management Foundation of the Harvard Medical Institutions.

Over the years, health systems have worked to improve medication safety by instituting barcodes, computer order entry and smart pumps, which is why the number of adverse drug events is surprising, said Dr. David Bates, the study’s lead author and chief of general internal medicine at Brigham and Women’s Hospital.

“It’s concerning,” he said. “The rates are higher than I thought they might be… It’s still very clear that patient safety is a big issue and it’s one that institutions and leaders need to pay attention to.”

More providers should focus on developing stronger decision support and leveraging free programs like Fall TIPS, an evidence-based intervention that uses bedside tools to communicate risk factors and creates tailored plans to prevent falls, Bates said. 

It’s also important for hospitals to use electronic health record data to look for signals that a patient may have had a harm event and identify areas to intervene earlier in patient care so harm doesn’t occur, he said. 

“Hospitals need to begin to measure the frequency of all types of harm that occur so that they can figure out which areas of harm they should prioritize at any given time,” Bates said.

Ultimately, the rate of adverse events across health systems is a reflection of the lack of investment in sustainable systems for quality and safety, said Stephanie Mercado, CEO of the National Association for Healthcare Quality.

When systems don’t have coordinated workforce support systems, there is little to no training to inform workers about what a safety event is, how to identify one and how to solve for them at a patient and system wide level, she said.

“We need to move from compliance with quality and safety standards, to this notion of excellence in quality and safety,” Mercado said. “Compliance represents a collection of activities that were developed as a result of something going badly, and excellence is much more aspirational and will help us achieve a future state where quality and safety are both the process and the outcome of our efforts.”

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