Hospital mishaps

Nearly one million patient-safety incidents occurred among Medicare patients over the years 2006, 2007, 2008, a figure virtually unchanged since last year’s annual study of patient safety by HealthGrades, an independent healthcare ratings organization.

The seventh annual HealthGrades Patient Safety in American Hospitals study evaluated 39.5 million hospitalization records from the nation’s nearly 5,000 nonfederal hospitals and used indicators developed by the federal Agency for Healthcare Research and Quality.

The incidents were associated with $8.9 billion in costs. One in 10 patients — 99,180 individuals — experiencing a patient-safety incident died as a result, the study found.

“It is disheartening, however, to see that the numbers have not changed since last year’s study and, in fact, certain patient safety incidents, such as post-operative sepsis, are on the rise,” HealthGrades noted in a statement.

STUDY FINDINGS
• Patients at hospitals in the best-performing top 5% experienced 43% fewer patient safety incidents, on average, compared to poorly performing hospitals. If all hospitals performed at this level, 218,572 patient safety incidents and 22,590 deaths could potentially have been avoided, saving $2 billion from 2006 through 2008.

• Patients treated at top-performing hospitals had, on average, a 43% lower chance of experiencing one or more medical errors compared to the poorest-performing hospitals.
Patient safety events are common at U.S. hospitals.

• Between 2006 and 2008 there were 958,202 total patient safety events among Medicare beneficiaries, representing 2.29% of the 39.5 million Medicare admissions.

• Between 2006 and 2008 these patient safety events were associated with more than $8.9 billion in excess costs.

• Some of the most common and most serious indicators worsened, accounting for 78.94% of the total patient safety incidents studied. These include decubitus ulcer (bed sores), iatrogenic pneumothorax (collapsed lung), post-operative hip fracture, post-operative physiologic and metabolic derangements, post-operative pulmonary embolism (potentially fatal blood clots forming in the lungs) or deep vein thrombosis (blood clots in the legs), post-operative sepsis, and transfusion reaction.

 • The patient safety incidents with the highest incidence rates are, along with the event rates per 1,000: failure to rescue (92.71), decubitus ulcer (36.05), post-operative respiratory failure (17.52) and post-operative sepsis (16.53).