While the number of patient safety incidents that occurred among hospitalized Medicare patients dipped slightly below the one million mark in 2009, the number of injured did not vary greatly from the rates in previous years, according to the new annual study from HealthGrades, an independent healthcare ratings organization based in Golden, CO.
Overall, the incidents created additional health costs of $8.9 billion annually. Also, 99,180 Medicare patients—a tenth of those who had experienced a patient safety incident—died as a result, according to HealthGrades' Patient Safety in American Hospitals study that examined data from nearly 5,000 nonfederal hospitals.
HealthGrades used indicators developed by the Agency for Healthcare Research and Quality (AHRQ) and Medicare to track patient safety incidents and identify which hospitals were in the top 5% in the nation in preventing patient safety incidents.
The report found that 238 top-performing hospitals, which received HealthGrades' "2010 Patient Safety Excellence Awards," had on average 43% fewer patient safety incidents, when compared with poorly performing hospitals. If each hospital operated at the level of the top 5% hospitals, HealthGrades estimated that 218,572 patient safety incidents—and 22,590 deaths—could have been avoided between 2006 to 2008, saving another $2 billion.
The findings that some indicators were worsening, such as for post-operative sepsis, over time "weren't surprising, but they were disappointing," says Rick May, MD, a HealthGrades vice president and study coauthor.
"There's been so much emphasis over the last few years from different governmental agencies like AHRQ and [others], such as the Institute for Healthcare Improvement, on really combating a lot of these patient safety type events," he says. "It's very disappointing that there hasn't been more movement on a nationwide basis, given the amount of attention, time, effort, and resources that have been put into making hospitals better in these areas."
Best practices addressing sepsis and central line infections have been established over the past few years, May adds.
"But one of the critical problems we see nationwide is that hospitals simply don't implement them; the knowledge is there, but they do not follow through on making sure that they're implementing those best practices on every single patient every single time."
HealthGrades also found: