Hospital Safety: NEJM Study Finds No Progress

In 1999, the Institute of Medicine issued a landmark report, To Err is Human, documenting the extraordinary rate of medical mistakes at U.S. hospitals: medical errors caused 98,000 deaths and more than a million injuries a year, most being preventable.  Two recent reports–one by a Harvard Medical School team, the other by the U.S. Inspector General of the DHHS–found NO IMPROVEMENT in patient safety at U.S. hospitals.

A large scale study by Harvard Medical School researchers selected 10 North Carolina hospitals for their analysis of patient safety, because North Carolina hospitals instituted programs to improve patient safety. Yet, contrary to expectaions, the researchers found a continuing hgh rate of problems:

A total of 588 harms were identified for 10,415 patient-days that were studied, for a rate of 56.5 harms per 1000 patient-days or 25.1 harms per 100 admissions. Some patients were harmed multiple times.   63.1% of the injuries were judged to be preventable.

Harms that were detected were a consequence of procedures (186), medications (162), nosocomial infections (87), other therapies (59), diagnostic evaluations (7), and falls (5), among other causes.

Severity of Harms Detected by Internal and External Reviewers in 10 North Carolina Hospital :

Of 588 harms that were identified, 245 (41.7%) were temporary harms requiring intervention, and 251 (42.7%) were temporary harms requiring initial or prolonged hospitalization. An additional 17 harms (2.9%) were permanent, 50 (8.5%) were life-threatening, and 14 (2.4%) caused or contributed to a patient’s death.

Similar appalling results were reported by the Inspector General of the DHHS (November 2020) Adverse Events in Hospitals focused on the care received by 1,000,000 Medicare beneficiaries who were discharged during the month of October, 2008:

One in 7–that is, 134,000 Medicare patients experienced "adverse events" during one month of a hospital stay–13.5%.

 In one month, medical errors resulted in the deaths of 225 patients (1.5% of 15,000).

Hospital care associated with adverse and temporary harm events cost Medicare an estimated $324 million in October 2008

The IG report stated that the extra treatment required as a result of injuries could cost taxpayers several billion dollars a year. 

This is but one deadly area of America’s broken healthcare system in need of meaningful reform. But given the lack of resolve by public policy makers–in government and the healthcare industry–no action is likely. 

To gain even greater insight into the our precarious, unsustainable disregard for the approaching storm–a veritable Tsunami–that threatens America’s standing and Americans’ standard of living, see,  " A Few Factoids" in a newly issued 5-year follow-up report by the Presidents of the National Academy of Sciences, National Academy of Engineering, and Institute of Medicine:  Rising Above the Gathering Storn, Revisited: Rapidly Approaching Category 5.

A few examples:

"The total annual federal investment in research in mathematics, the physical sciences and engineering is now equal to the increase in United States healthcare costs every nine weeks." 

 "According to OECD data the United States ranks 24th among thirty ealthy countries in life expectancy at birth."

"Ninety-three percent of United States public school students in fifth hrough eighth grade are taught the physical sciences by a teacher without a degree or certificate in the physical sciences."

"United States consumers spend significantly more on potato chips than he government devotes to energy R&D."

"The World Economic Forum ranks the United States 48th in quality of athematics and science education."

  "China has now replaced the United States as the world’s number one high-technology exporter. In 1998 China produced about 20,000 research articles, but by 2006 the output had reached 83,000 . . . overtaking Japan, Germany and the U.K ""

 

 

Posted: Vera Hassner Sharav

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Temporal Trends in Rates of Patient Harm Resulting from Medical Care

Christopher P. Landrigan, M.D., M.P.H., Gareth J. Parry, Ph.D., Catherine B. Bones, M.S.W., Andrew D. Hackbarth, M.Phil., Donald A. Goldmann, M.D., and Paul J. Sharek, M.D., M.P.H.

N Engl J Med 2010; 363:2124-2134 November 25, 2010

In the 10 years since publication of the Institute of Medicine’s report To Err Is Human, extensive efforts have been undertaken to improve patient safety. The success of these efforts remains unclear.

Methods

We conducted a retrospective study of a stratified random sample of 10 hospitals in North Carolina. A total of 100 admissions per quarter from January 2002 through December 2007 were reviewed in random order by teams of nurse reviewers both within the hospitals (internal reviewers) and outside the hospitals (external reviewers) with the use of the Institute for Healthcare Improvement’s Global Trigger Tool for Measuring Adverse Events. Suspected harms that were identified on initial review were evaluated by two independent physician reviewers. We evaluated changes in the rates of harm, using a random-effects Poisson regression model with adjustment for hospital-level clustering, demographic characteristics of patients, hospital service, and high-risk conditions.

Results

Among 2341 admissions, internal reviewers identified 588 harms (25.1 harms per 100 admissions; 95% confidence interval [CI], 23.1 to 27.2). Multivariate analyses of harms identified by internal reviewers showed no significant changes in the overall rate of harms per 1000 patient-days (reduction factor, 0.99 per year; 95% CI, 0.94 to 1.04; P=0.61) or the rate of preventable harms. There was a reduction in preventable harms identified by external reviewers that did not reach statistical significance (reduction factor, 0.92; 95% CI, 0.85 to 1.00; P=0.06), with no significant change in the overall rate of harms (reduction factor, 0.98; 95% CI, 0.93 to 1.04; P=0.47).

Conclusions

In a study of 10 North Carolina hospitals, we found that harms remain common, with little evidence of widespread improvement. Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time. (Funded by the Rx Foundation.)

See: Complete text accessible 

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THE NEW YORK TIMES
November 24, 2010

Study Finds No Progress in Safety at Hospitals
By DENISE GRADY

Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.

The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.

“It is unlikely that other regions of the country have fared better,” said Dr. Christopher P. Landrigan, the lead author of the study and an assistant professor at Harvard Medical School. The study is being published on Thursday in The New England Journal of Medicine.

It is one of the most rigorous efforts to collect data about patient safety since a landmark report in 1999 found that medical mistakes caused as many as 98,000 deaths and more than one million injuries a year in the United States. That report, by the Institute of Medicine, an independent group that advises the government on health matters, led to a national movement to reduce errors and make hospital stays less hazardous to patients’ health.

Among the preventable problems that Dr. Landrigan’s team identified were severe bleeding during an operation, serious breathing trouble caused by a procedure that was performed incorrectly, a fall that dislocated a patient’s hip and damaged a nerve, and vaginal cuts caused by a vacuum device used to help deliver a baby.

Dr. Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.  But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found.

The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

“Until there is a more coordinated effort to implement those strategies proven beneficial, I think that progress in patient safety will be very slow,” he said.

An expert on hospital safety who was not associated with the study said the findings were a warning for the patient-safety movement. “We need to do more, and to do it more quickly,” said the expert, Dr. Robert M. Wachter, the chief of hospital medicine at the University of California, San Francisco.

A recent government report found similar results, saying that in October 2008, 13.5 percent of Medicare beneficiaries — 134,000 patients — experienced “adverse events” during hospital stays. The report said the extra treatment required as a result of the injuries could cost Medicare several billion dollars a year. And in 1.5 percent of the patients — 15,000 in the month studied — medical mistakes contributed to their deaths. That report, issued this month by the inspector general of the Department of Health and Human Services, was based on a sample of Medicare records from patients discharged from hospitals.

Dr. Landrigan’s study reviewed the records of 2,341 patients admitted to 10 hospitals — in both urban and rural areas and involving large and small medical centers. (The hospitals were not named.) The researchers used a “trigger tool,” a list of 54 red flags that indicated something could have gone wrong. They included drugs used only to reverse an overdose, the presence of bedsores or the patient’s readmission to the hospital within 30 days.

The researchers found 588 instances in which a patient was harmed by medical care, or 25.1 injuries per 100 admissions.

Not all the problems were serious. Most were temporary and treatable, like a bout with severe low blood sugar from receiving too much insulin or a urinary infection caused by a catheter. But 42.7 percent of them required extra time in the hospital for treatment of problems like an infected surgical incision.

In 2.9 percent of the cases, patients suffered a permanent injury — brain damage from a stroke that could have been prevented after an operation, for example. A little more than 8 percent of the problems were life-threatening, like severe bleeding during surgery. And 2.4 percent of them caused or contributed to a patient’s death — like bleeding and organ failure after surgery.

Medication errors caused problems in 162 cases. Computerized systems for ordering drugs can cut such mistakes by up to 80 percent, Dr. Landrigan said. But only 17 percent of hospitals have such systems. For the most part, the reporting of medical errors or harm to patients is voluntary, and that “vastly underestimates the frequency of errors and injuries that occur,” Dr. Landrigan said.

“We need a monitoring system that is mandatory,” he said. “There has to be some mechanism for federal-level reporting, where hospitals across the country are held to it.”

Dr. Mark R. Chassin, president of the Joint Commission, which accredits hospitals, cautioned that the study was limited by its list of “triggers.” If a hospital had performed a completely unnecessary operation, but had done it well, the study would not have uncovered it, he said. Similarly, he said, the study would not have found areas where many hospitals have made progress, such as in making sure that patients who had heart attacks or heart failure were sent home with the right medicines. The bottom line, he said, “is that preventable complications are way too frequent in American health care, and “it’s not a problem we’re going to get rid of in six months or a year.”

Dr. Wachter said the study made clear the difficulty in improving patients’ safety.

“Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

Leah Binder, the chief executive officer of the Leapfrog Group, a patient safety organization whose members include large employers trying to improve health care, said it was essential that hospitals be more open about reporting problems.

“What we know works in a general sense is a competitive open market where consumers can compare providers and services,” she said.

“Right now you ought to be able to know the infection rate of every hospital in your community.”

For hospitals with poor scores, there should be consequences, Ms. Binder said: “And the consequences need to be the feet of the American public.”