AHRQ: Rate of Adverse Events in Medicare Cases 'Disturbing'

John Commins, for HealthLeaders Media , November 17, 2010

One in seven Medicare beneficiaries suffers an adverse event during a hospital stay, and those events, nearly half of them preventable, contributed to at least 15,000 deaths in a single month, a federal study has found.

The adverse events included the National Quality Forum Serious Reportable Events; Medicare hospital-acquired conditions; and events resulting in prolonged hospital stays, permanent harm, life-sustaining intervention, or death.

The incidence rate projects to about 134,000 Medicare beneficiaries—13.5%—experiencing at least one adverse event in hospitals during a single month, with events contributing to the deaths of about 15,000 beneficiaries, according to the audit by the Department of Health and Human Services' Office of Inspector General. 

Physician reviewers for OIG determined that 44% of adverse events were preventable, most commonly because of medical errors, substandard care, and inadequate patient monitoring. Additional hospital care necessitated by these events consumed an estimated 3.5% of Medicare's inpatient expenditures for the sample month—about $4.4 billion in Medicare costs annually. Two-thirds of these costs were the result of additional hospital stays, the study found. 

OIG recommended that the Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services lead national efforts to reduce events, broaden patient safety efforts to include all types of adverse events, and enhance efforts to identify events. OIG wants CMS to provide more incentives for hospitals to reduce adverse events through its payment and oversight functions, including strengthening the Medicare hospital-acquired conditions policy, and holding hospitals accountable for adopting evidence-based practices.

In a letter to HHS Inspector General Daniel R. Levinson, CMS Administrator Donald Berwick, MD, said the report demands that "solutions need to be addressed as quickly and as efficiently as possible." Berwick said CMS has taken action on some of the issues but "more work needs to be done," and that CMS would play a more proactive role in providing "a culture of safety across the country in all healthcare settings."

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