These events cost Medicare and patients hundreds of millions of dollars for October 2018.
A new study by the Office of Inspector General (OIG) finds that 25 percent of Medicare patients experienced harm events during their hospital stays in October 2018. Twelve percent of patients included adverse events that led to longer hospital stays, permanent harm, life-saving intervention, or death.
The latest report is a follow-up to the OIG’s 2010 report, which provided the first national incidence rate of patient harm events in hospitals. At that time, the federal watchdog found that 27 percent of hospitalized Medicare patients experienced harm in October 2008. Hospital care associated with these events cost Medicare and patients an estimated $324 million in reimbursement coinsurance and deductible payments. OIG determined that nearly half of these events were preventable.
OIG said it conducted the new study to update the national incidence rate and calculate a new rate of preventable events and updating the cost of patient harm to the Medicare program.
OIG analysts reviewed medical records for a random sample of 770 Medicare patients who were discharged from acute care hospitals during October 2018. Researchers conducted a two-stage medical record review to estimate a national incidence rate of adverse events and temporary harm events. The review included all causes of patient harm regardless of whether the harm was preventable.
The study included several stages:
First, nurses screened the records for possible patient harm events using a "trigger tool" method or a clinical clue, such as documentation of a fall, which may indicate harm. From the Medicare claims data, nurses reviewed present-on-admission indicators to identify harm that developed after the patient was admitted. OIG automatically referred records to the second stage when patients were readmitted within 30 days of discharge, regardless of whether the nurse identified harm (these include readmissions in October and November).
During the second stage, physicians reviewed the records flagged during the first stage as containing possible harm events. Physician reviewers then determined which ones were harm events and assessed the severity of events, whether they were preventable, and factors that contributed to events.
OIG then calculated the potential cost incurred by Medicare and patients because of these events. Researchers also determined whether events were on CMS's lists of hospital-acquired conditions (HAC). Finally, researchers compared the results of this report to the 2010 report and explained the limitations of this comparison.
Here are 10 key findings:
- Twenty-five percent of Medicare patients experienced patient harm during their hospital stays in October 2018.
- Twelve percent of patients experienced adverse events that led to longer hospital stays, permanent harm, life-saving intervention, or death.
- Thirteen percent of patients experienced temporary harm events, which required intervention but did not cause lasting harm, prolong hospital stays, or require life-sustaining measures. Temporary harm events were sometimes serious and could have caused further harm if providers had not promptly treated patients.
- The most common type of harm event (43 percent) was related to medication, such as patients experiencing delirium or other changes in mental status.
- Other types of harm events were related to patient care (23 percent), such as pressure injuries; procedures and surgeries (22 percent), such as intraoperative hypotension; and infections (11 percent), such as hospital-acquired respiratory infections.
- Forty-three percent of harm events were preventable. Physician reviewers said preventable events were commonly linked to substandard or inadequate care provided to the patient. (OIG said the overall harm rate would be 13 percent if it included only events that physician-reviewers determined were preventable.)
- Fifty-six percent of harm events were not preventable and occurred even though providers followed proper procedures. OIG said events were determined not preventable for several reasons, including that the patients were found to be highly susceptible to the events because of their poor health status.
- Of the harm events identified, only five percent were on CMS' HAC Reduction Program list and only two percent were on CMS' Deficit Reduction Act HAC list.
- Nearly a quarter of Medicare patients who experienced harm events, either preventable or nonpreventable, required treatment that led to additional Medicare costs.
- Costs incurred for all events are estimated to be in the hundreds of millions of dollars for October 2018.
OIG urged the Department of Health & Human Services (HHS) and agencies to work to reduce patient harms in hospitals. Among its recommendations to the Centers for Medicare & Medicaid Services (CMS):
- Update and broaden its lists of HACs to capture common, preventable, and high-cost harm events
- Expand the use of patient safety metrics in pilots and demonstrations for health care payment and service delivery, as appropriate
- Develop and release interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm
The agency agreed and, in response to the OIG draft report, CMS provided details about ongoing and planned efforts to improve patient safety.