According to HealthGrades’ sixth annual Patient Safety in American Hospitals Study, a total of 913,215 patient safety events occurred among Medicare beneficiaries between 2005 and 2007, amounting to one patient safety event every 1.7 minutes. The study also showed “large safety gaps” between top- and bottom-ranked hospitals, estimating that approximately 211,697 patient safety events and 22,771 deaths among Medicare beneficiaries could have been avoided if all hospitals performed at the level of the survey’s top-ranked facilities.
HealthGrades used patient safety indicators from the Agency for Healthcare Research and Quality (AHRQ) to identify the patient safety incidence rates for every non-federal hospital in the country using three years of Medicare data (2005–2007).
From 2005 through 2007 there were 913,215 total patient safety events among 864,765 Medicare beneficiaries which represents 2.3 percent of the nearly 38 million Medicare hospitalizations. These patient safety events were associated with over $6.9 billion of excess cost. There were 97,755 actual inhospital deaths that occurred among patients who experienced one or more of the 15 patient safety events. Medicare patients who experienced one or more of the 15 patient safety events had approximately a one-in-ten chance of dying as a result of an event from 2005 through 2007.
•· The overall incidence rate remained virtually unchanged compared to last year’s study (except the failure to rescue indicator for which there were major methodological changes).
•· Eight indicators showed improvement over the course of the study. Complications of anesthesia, death in low mortality DRGs, failure to rescue, iatrogenic pneumothorax, selected infections due to medical care, post-operative hip fracture, postoperative hemorrhage or hematoma, and transfusion reaction showed improvement ranging from 2.3 percent to 52.0 percent. These eight indicators accounted for 14.5 percent of the total patient safety events during the study period.
•· Seven indicators worsened over the course of the study. Decubitus ulcer (bed sores), post-operative physiological and metabolic derangements, post-operative respiratory failure, post-operative pulmonary embolism (potentially fatal blood clots forming in the lungs) or deep vein thrombosis (blood clots in the legs), postoperative sepsis, post-operative abdominal wound dehiscence, and accidental puncture or laceration all worsened with changes ranging from a one-percent increase in events to 23.4 percent. These seven indicators accounted for 85.5 percent of the total patient safety events during the study period.
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(SOURCES: The Advisory Board Daily Briefing, http://advisory.com, April 8, 2009)