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Patient Safety Events Occur in a Quarter of Inpatient Hospitalizations
Of the adverse patient safety events that occurred in 2018, 23 percent were deemed preventable, and 32 percent were marked with high clinical severity.
Nearly a quarter of the inpatient hospital visits in Massachusetts in 2018 had at least one adverse patient safety event, with quarter of those patient safety issues being preventable, according to new data from Mass General Brigham and CRICO, the medical professional liability insurer for the Harvard medical community and its affiliated organizations.
The results, published in the New England Journal of Medicine, may be applicable nationwide and, at the very least, point to renewed interest in improving patient safety.
This study follows up on the 30-year-old Harvard Medical Practice Study (HMPS), which the researchers said illuminated the problem of patient safety and sparked an industry effort to eliminate patient harm in the inpatient setting.
The ways healthcare professionals can measure patient safety have changed since HMPS was published, but the researchers used similar design principles to assess how patient safety has changed in the decades that have passed. The team analyzed 2,800 patient charts for large, medium, and small inpatient hospital visits in 2018 and found that adverse patient safety events are still rampant.
There was at least one adverse event in 23.6 percent of all admissions during the study period, the researchers said, and of those events, 23 percent were preventable given today’s healthcare knowledge landscape. Around a third (32 percent) had serious or higher clinical severity, the research team reported.
“The study clearly demonstrates a need for better tools, increased measurement of patient harm, and better implementation systems,” corresponding author David Westfall Bates, MD, medical director of Clinical and Quality Analysis for Mass General Brigham and chief of General Internal Medicine at Brigham and Women’s Hospital, said in a statement.
“While we looked at hospitals in Massachusetts, improving the delivery of safe care is a national issue, not one that is specific to one hospital, system, state, or region,” Westfall Bates added. “It’s valuable to know how much harm there is and for every institution to be aware of trends in adverse events so that they can take steps to mitigate and address issues within their walls.”
The analysis revealed key causes of patient harm, including medication-related events (39 percent of adverse events), surgery and procedural events (30 percent), patient care issues like falls and pressure ulcers (15 percent), and healthcare-associated infections (12 percent).
The researchers indicated that there’s significant room for patient safety improvement, noting that the rate of adverse patient safety events was higher in this most recent study than in the HMPS study done 30 years ago (although the team also acknowledged they defined patient harm differently).
But to achieve that improvement, healthcare leaders will need to think differently about the systems that promote patient safety. Healthcare has evolved to administer more and more complex care in ambulatory settings, leaving inpatient beds for the highest-acuity cases most likely to yield a patient safety event.
But EHRs and digital clinical documentation may open new doors to care for the sickest of individuals who are taking up most inpatient beds, the researchers said.
“Because records are now computerized in nearly all hospitals, it should be possible to search them to make identification of these events much easier, which should in turn make it easier for hospitals to manage this area more effectively,” Bates explained.
“Based on our study, we are now taking steps to ensure that key findings do not get lost. We are also evaluating technological solutions that may help us better detect changes in respiratory rates, a patient’s pulse, and other early warning signs so that we can take steps to prevent or mitigate adverse events before they can cause harm.”
Healthcare can may inroads in patient safety by better tracking adverse drug events and documenting data in a more routine fashion, the researchers advised. After all, you cannot improve what you do not measure, Bates indicated.
“It’s important to do the work to identify adverse events if we’re going to work to improve them,” he said. “All organizations should have approaches for monitoring these things on a regular basis.”
Patient safety is an urgent need for an industry characterized by worker burnout and shortages, according to Elizabeth Mort, MD, senior vice president of Quality and Safety at Massachusetts General Hospital and a co-author of the study. Low staffing levels have been linked with higher instances of adverse patient safety events.
Organizations need to invest in the measurement and monitoring systems necessary to improve patient safety as healthcare adjusts to a post-pandemic landscape.
“Our work is a call to action for those from board to bedside to ensure reducing preventable patient harm is a top priority,” Mort said in the press release. “Keep in mind that our study looked at patient safety before the COVID-19 pandemic. We know that our industry is now facing economic, workforce and wellness challenges nationally. Given these pressures, remaining focused and committed to patient safety is more important than ever.”
