NEARLY ONE-QUARTER (23.6%) of patients admitted to a hospital experience an adverse event. Nearly one-quarter (23%) of those events were preventable and 32% had a serious or higher level of severity.
Those data came from a study of 11 Massachusetts hospitals that was published in the New England Journal of Medicine. Researchers looked at admissions in 2018 from a mix of large and small hospitals that were part of three health care systems in the state.
Of just under 3,000 admissions, 978 experienced some kind of adverse event (AE). A preventable AE occurred in 7% of all admissions, and a preventable AE with a severity level of serious or higher occurred in 1%, or 29, admissions in the study.
Researchers defined serious events as those where harm resulted in substantial intervention or prolonged recovery. Only two categories—life-threatening and fatal—were worse.
Researchers also found seven deaths among the admissions. One was preventable.
The data found that the most common AEs were drug problems, which accounted for 39% of all events. Surgical or other procedural events accounted for 30%, and events like falls and pressure ulcers accounted for 15%. Health care associated infections accounted for 12% of inpatient AEs.
The authors noted that while there’s been an overall decrease in health care associated infections, progress on other safety measures can be difficult to quantify.
Adverse drug events, for example, aren’t routinely measured by hospitals, so it’s harder to track their incidence and hospitals’ success preventing them. Researchers also say that adverse drug events happen more frequently than suggested by voluntary reporting would indicate.
Some data show these events may be 20 times more prevalent than voluntarily reported data would indicate.
Sounds like an opportunity for improvement using some of the QI tools at our disposal, e.g. RCA, FMEA, DMAIC, etc. I’m sure that these hospitals are in the process of moving the needle using science.
All oncologists should immediately stop giving chemotherapy since the resultant effects on the bone marrow will result in an adverse event being recorded. Neutropenia, anemia and thrombocytopenia are not acceptable. Likewise, hypokalemia after furosemide; we must stop treating heart failure with diuretics.
Or the other option is for patients to stop seeking care in Massachusetts.