Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018
One quarter of Medicare patients experienced patient harm during their hospital stays in October 2018, according to a new report. The report, from the Office of Inspector General (OIG) at the Department of Health and Human Services (HHS), is an update to a 2010 study in which OIG reported the first national incidence rate of patient harm events in hospitals, with 27% of hospitalized Medicare patients experiencing harm in October 2008. According to the report, hospital care associated with those events cost approximately $324 million in reimbursement, coinsurance, and deductible payments. The new study involved a two-stage medical record review for a random sample of 770 Medicare patients who were discharged from acute-care hospitals during October 2018. Of the 25% of patients who experienced patient harm during their stays, 12% experienced adverse events — resulting in longer hospital stays, permanent harm, life-saving interventions, or death — while 13% had temporary harm events. These necessitated intervention but did not result in lasting harm, extend hospital stays, or require life-sustaining measures. The most frequent kind of harm event involved medication, followed by patient care, procedures and surgeries, and infections. Overall, 43% of the harm events were deemed preventable, according to physician-reviewers. OIG made seven recommendations to the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ). It recommended that CMS update and expand its list of hospital-acquired conditions to capture frequent, preventable, and high-cost harm events; consider expanding the use of patient safety metrics in pilots and demonstrations for healthcare payment and service delivery; and develop and issue interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm. Recommendations for AHRQ included, with support from HHS leadership, coordinating agency efforts to update agency-specific Quality Strategic Plans; optimizing use of the Quality and Safety Review System; developing an effective model to disseminate information on national clinical practice guidelines or best practices to increase patient safety; and continuing efforts to identify and create new efforts to prevention common patient harm events in hospitals.
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