Nearly a quarter of hospitalized patients in the United States experience an adverse event such as a drug-related harm, pressure injury or infection during care, according to a new study.
The study, which looked at a random sample of 2,809 hospitalizations from 11 Massachusetts hospitals in 2018, found that of the adverse events, 22.7% were considered preventable and 32.3% were preventable. classified as serious, life-threatening, or fatal. The study was published Wednesday in the New England Journal of Medicine.
“It’s a serious condition, with a high rate of harm,” said Dr Peter Pronovost, director of clinical quality and transformation at University Hospitals in Cleveland, who was not involved in the study. “What’s worrying is that we don’t seem to have a major trend, despite decades of research on this.”
The findings are similar to those detailed in the Office of Inspector General’s patient harms report published in May. That report found that one in four Medicare patients suffered a patient injury during a short-term, acute care hospital stay.
Provonost said that while some patient safety measures such as those around infection control have gradually improved, results have not improved significantly since the study’s publication. The 1991 Harvard Medical Practice study, which raised alarm bells nationally on the subject of patient safety.
The current study found that seven deaths were the product of harmful events, one of which is considered preventable. adverse drug events accounted for 39% of all events; other surgical or procedural events accounted for 30.4%; patient care events, including falls and pressure ulcers, accounted for 15%; and medical-related infections was 11.9%.
The researchers found that of all hospitalized patients, 6.8% experienced preventable side effects and 1% experienced preventable side effects ranging in severity from serious weight or more.
The study was funded by a grant from the Controlled Risk Insurance Company of Vermont and the Harvard Medical Institutions Risk Management Fund.
Over the years, health systems have worked to improve drug safety by establishing barcodes, order entry computers, and smart pumps, which is why the number of drug side effects surprising, said Dr. David Bates, lead author of the study and head of home affairs at large. medicine at Brigham and Women’s Hospital.
“It’s concerning,” he said. “The rate is higher than I thought… It’s still very clear that patient safety is a big deal and it’s an issue that organizations and leaders need to pay attention to.”
Bates said more providers should focus on developing stronger decision support and taking advantage of free programs like Fall TIPS, an evidence-based intervention that uses bedside tools to Communicate risk factors and create appropriate plans to prevent falls.
It is important for hospitals to use electronic health record data, he said, to look for signals that a patient may have experienced a damaging event and identify areas of need. intervene earlier in patient care so that harm does not occur.
“Hospitals need to start measuring how often all types of harm occur so they can figure out which areas of harm they should prioritize at any given time,” says Bates.
Ultimately, the rate of adverse events in health systems reflects a lack of investment in quality sustainable systems, said Stephanie Mercado, CEO of the National Association for Health Quality. and safe.
When systems do not have coordinated workforce support systems, there is little or no training to inform workers about what a safety event is, how to identify an event, and how to do it. addressing them at the patient and system-wide level, she said.
“We need to move from compliance with quality and safety standards to a concept of quality and safety excellence,” said Mercado. “Compliance represents a set of activities developed as a result of something bad, and excellence is much more aspirational and will help us achieve a state in the future. , where quality and safety are both the process and the result of our efforts.”
