Since publication of the National Academy of Medicine's 2000 report, To Err is Human: Building a Safer Health System, strategies for preventing specific types of patient safety problems have become ubiquitous. Hospitals monitor the number and types of falls, pressure injuries, and infections and have instituted research-based prevention protocols. The Centers for Medicare and Medicaid Services now imposes financial penalties on hospitals where selected adverse events have occurred. But despite these measures, new research finds that the hoped-for progress in substantially decreasing the incidence of adverse events has not been achieved.
A study in the New England Journal of Medicine looked at a randomly selected sample of 2,809 inpatient admissions to 11 Massachusetts hospitals in 2018. Patients admitted for hospice care, rehabilitation, psychiatry, addiction treatment, or observation were excluded. The severity of each adverse event was categorized as significant (unnecessary harm but rapid recovery), serious (harm necessitating substantial intervention or prolonged recovery), life-threatening, or fatal.
Nearly one-quarter (23.6%) of patients in the sample experienced at least one adverse event; 18.6% experienced at least one "significant" event, 7.5% at least one "serious" event, 1.2% at least one life-threatening event, and 0.2% at least one fatal event. The researchers described nearly one-quarter of these adverse events as preventable.
Event rates at the 11 hospitals ranged from 15.1 to 47 events per 100 admissions, with higher rates at larger hospitals. Older patients experienced more adverse events than younger patients, and men more adverse events than women. The mean length of stay for patients with at least one adverse event was more than twice that of patients without an adverse event.
Overall, 39% of adverse hospital events were drug related, 30.4% were related to surgical or other procedures, 15% were "patient care events" such as falls and pressure injuries, and 11.9% were health care-associated infections. Adverse events that involved surgery or other procedures were most likely to be in the "life-threatening" category, while health care-associated infections were most likely to result in fatalities.
The researchers noted that although data recently published in JAMA showed a 10-year decline in the rate of certain adverse events-especially health care-associated infections, adverse drug events, and some patient care-related events-data from 2020 cited in a recent commentary suggest that pressures on the health care system as a result of the COVID-19 pandemic may have reversed these trends.-Betsy Todd, MPH, RN