Patient Safety Statistics

Missouri Purges Data From Infection Records

An article by Jim Doyle exposes the fact that the State of Missouri has deleted hospital infection data from their records citing that it is too costly to maintain and too sensitive for the public to review for more than a year. 

Doyle writes:  "Without access to infection data from previous years, consumers won't be able to adequately assess a hospital's performance in preventing infections, consumer advocates say. Specifically, the policy of the Department of Health and Senior Services makes it difficult to review how hospitals have performed over time and whether they perform consistently above or below the national average."

This decision to purge data has stirred a heated political, legal and social debate regarding public health records. 

Rep. Rob Schaaf, R-St. Joseph, a family-practice physician who pushed the infection bill in the Legislature is quoted as saying, "It's pretty sad to me that the (health) department can't give you a trend to show that a hospital is getting better or worse. It shows that the department doesn't really care,"

Senator Sarah Steelman, one of the original bill's sponsors, said "I'm surprised at the agency. The job of the health department is to protect people. It makes no sense at all to eliminate data after one year."

Ken Bunting, executive director of the National Freedom of Information Coalition, weighed in on the topic by stating, "It sounds like they're violating the spirit if not the letter of the law, If it's being posted online, they don't need to take it down."

To read Doyle's entire article please visit "Missouri Purges Data From Infection Records".

No Reduction in Patient Safety Incidents at Hospitals

19090338 According to a new HealthGrades, Inc. study released today, there were at least one million patient safety incidents at hospitals between the years 2006-2008.  This figure is unchanged since last year's study.  Together, these incidents cost the nation almost $9 billion.  Even more tragic than the costs is the fact that one in ten of these incidents ended in death.  HealthGrades uses measures called patient safety indicators from the Agency for Healthcare Research and Quality to analyze hospital safety.

Physicians Not Optimistic About Quality Trends

Yesterday, Sermo, Inc. and athenahealth released a joint survey of 1,000 physicians called the Physician Sentiment Index.  The first survey of its kind, it suggests that physicians are pessimistic about the future of health care.  In fact,

  • 64% say that the health care environment is detrimental to their delivery of quality care
  • 59% believe the quality of medicine will decline in America over the next five years

Despite the medical advances that enter into the health care delivery system on an ongoing basis, only 18% believe that the quality of medicine will improve over the next five years.  However, seven in ten physicians believe that electronic health records can help reduce medical errors and improve physician compliance with clinical guidelines and feel that the benefits justify the costs of installing such systems.

AHRQ Updates Data Standards for Patient Safety Organizations

39161571 The Patient Safety and Quality Improvement Act of 2005 aims to improve the safety and quality of health care in the U.S. through voluntary reporting by clinicians and health care organizations of patient safety and quality information without fear of legal discovery.  The basic idea is that if every health care provider shares information about incidences in which patients were adversely affected, we can aggregate and analyze these experiences to gain more insight into how to improve care. 

The Act charged the Agency for Healthcare Research and Quality (AHRQ) with creating standards for data submitted to Patient Safety Organizations.  Without data standards, aggregating and analyzing the data will be as difficult as comparing the proverbial apple to an orange.

AHRQ initiated standards development process by issuing and working with Version 0.1 Beta, but now has announced in the Federal Register the release of Common Formats Version 1.0.  The Common Formats span definitions and reporting formats and relate to all patient safety concerns, including healthcare-associated infections, falls and pressure ulcers.  This is an important step forward in realizing the goals of the Act.

New Poll Suggests 18% of Americans Affected by Hospital Infections

24724244 Consumers Union conducted a poll during mid-March of more than 2,000 Americans to learn about their experiences with health care-associated infections, preventable medical errors and preventive care.  Almost one in five (18%) say they or an immediate family member have experienced a dangerous infection following a medical procedure. 

  • Sixty nine percent of these respondents said they had to be admitted to a hospital or extend their stay because of these infections.

One-third of the Americans surveyed report that medical errors are common in everyday medical procedures.

  • Thirteen percent have had their medical records lost or misplaced.
  • Nine percent have been given the wrong medicine by a pharmacist when filling their doctor's prescriptions.

The results of the poll were released at a Congressional briefing on reforming the health care delivery system with the American Cancer Society, the American Diabetes Association, and the American Heart Association, who together also released a joint statement.

New AHRQ Study Finds Surgical Errors Cost Almost $1.5 Billion Each Year

A new study by William E. Encinosa, Ph.D. and Fred J. Hellinger, Ph.D. of the U.S. Agency for Healthcare Research and Quality (AHRQ) reveals that potentially preventable medical errors that occur during or after surgery may cost employers as much as $1.5 billion each year.

Published in the July 28, 2008 issue of Health Services Research, the researchers found that insurers pay additional costs for surgery patients who experienced the following conditions associated with medical errors compared to patients who did not:

  • acute respiratory failure - $28,218 (52% more)
  • Post-operative infections - $19,480 (48% more)
  • errors related to nursing care, such as pressure ulcers and hip fractures -$12,196 (33% more)
  • metabolic problems, including kidney failure or uncontrolled blood sugar - $11,797 (32% more)
  • blood clots or other vascular or pulmonary problems - $7,838 (25% more)
  • wound opening - $1,426 (6% more)

The study is based on a nationwide sample of more than 161,000 patients age 18-64 in employer-based plans who underwent surgery between 2001 and 2002, and used AHRQ's Patient Safety Indicators to identify medical errors. 

The authors conclude that studies focusing only on medical errors incurred during the initial hospital stay may underestimate the financial impact of patient safety events by as much as 30%.

Interview Series: Dr. Meghan Dierks discusses how HVA increases hand-hygiene compliance

As we continue our interview series with today’s thought leaders in patient safety, we spoke with Dr. Meghan Dierks, Assistant Professor, Harvard Medical School.

HVA (Hospital Video Auditing) is an innovative, non-intrusive, 24/7 auditing technology that significantly improves compliance with patient safety and hand washing practices and protocols

In structuring the HVA program at a surgery center in the southeastern United States, Dr. Dierks has witnessed compliance scores soar from 35% to 90%+... and even more striking, she's seen compliance rates remain there.

In what ways, and to meet which specific goals, is the healthcare facility using HVA?

"We applied the technology to tackle a refractory problem in the healthcare compliance arena--the very basic safety protocol revolving around hand-hygiene and getting physicians to modify their safety behavior. The technology was two-fold: first, it would provide us the ability to collect highly reliable data and we hadn't been able to in the past. And, second, by nature of collecting high-quality data and instilling a feedback loop to relay that data to physicians practicing in that environment we could achieve a behavioral change.

We had two goals, both of which were achieved through the use of HVA. First, we needed to be able to collect highly reliable data over a sustained period of time on hand hygiene behaviors--something that has been difficult to achieve using other strategies. Second, in order to achieve a behavioral change, we needed to be able to use this data to provide continuous performance feedback to the healthcare workers practicing in that environment."

What significant points of success and improvements have you witnessed from the surgery center using the technology?

"Prior published studies have demonstrated that other efforts and interventions--such as employing human observers or posting educational signage--achieve short term, but not sustainable improvements in compliance. HVA is a highly reliable data-collection technique that enabled us to continuously measure performance over a long period of time in the surgery center, and document positive movement toward an established goal.

We are now reaching our sixth month of continuous measurement and feedback. Using HVA, we identified a relatively low baseline compliance rate of 38%. We provided weekly feedback, and over the next several weeks, saw dramatic improvements in compliance. This relatively high compliance rate has now been sustained in the 88%-98% range for six months. While the fact that we achieved 98% compliance within four weeks is remarkable, equally striking is the sustainability of the behavior change."

Continue reading "Interview Series: Dr. Meghan Dierks discusses how HVA increases hand-hygiene compliance" »

HAIs on the rise in NY State

According to KaiserNework.org, the rate of hospital-acquired infections (HAIs) has increased in New York State. What isn't clear is whether the rise is due to an actual increase in HAIs or the ability of the state to better track a larger number of them. According to Kaiser's report:

"The report found that about 3,200 of 1.45 million hospitalizations resulted in a hospital-acquired infection in the state, an increase from about 2,900 out of 1.48 million hospitalizations a year earlier. Coalition President Bruce Boissonnault said that the number represents "a small fraction of the infections. For example, many people do not show symptoms of an infection until they're discharged, and those patients would not be in that sample (used in the study)." This is the first year a health trend has worsened since the coalition began conducting the study six years ago, the AP/Times Union reports."

The report also cites that the overall likelihood of dying from a hospital procedure decreased from 8.5% for eight inpatient procedures in 2002 to 7.4% in 2006. State Health Department spokesperson Jeffrey Hammond said, "While it may be possible that infection rates are getting worse, it may also be true that hospitals are more vigilant at reporting infections, and that's good news for patients".

Transparency in reporting is a good and necessary first step in acknowledging the problem but we need to understand the full range of infections we need to be reporting against--and the practices and technologies that all hospitals should be implementing in order to eradicate them. Then the numbers will serve us in not only tracking the breadth of HAIs and their main causes, but the successes of hospitals that have initiated better protocols, tests and auditing systems.

Summary of report located here. 2008 New York State Hospital Report Card is available online.

CDC Data Flawed, Regulations Too Lax?

In taking a strong stance with the CDC through an April 15th Commentary in The Washington Times before her testimony to Congress, Betsy McCaughey, Chairman of The Committee to Reduce Infection Deaths (RID), writes:

"Tomorrow Congress will hold hearings on whether the federal government is doing enough to prevent deadly hospital infection. The answer is 'no.' The biggest culprit is the CDC. The CDC claims 1.7 million people contract infections in U.S. hospitals each year. The truth is several times that number."

MCaughey then discusses the growing numbers of MRSA and how that alone skews the CDC's numbers:

One of the fastest growing infections is "Mersa" or MRSA, which stands for methicillin-resistant Staphylococcus aureus, a superbug that doesn't respond to most antibiotics. In 1993, there were fewer than 2,000 MRSA infections in U.S. hospitals. By 2005, the figure had shot up to 368,000 according to the Agency for Healthcare Research and Quality. By June, 2007, 2.4 percent of all patients had MRSA hospital infections, according to the largest-ever study, published in the American Journal of Infection Control. That would mean 880,000 victims a year.

That's from one superbug. Imagine the number of infections from bacteria of all kinds, including such killers as VRE (vancomycin-resistant Enterococcus) and C. diff (Clostridium difficile). Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention, recently told Congress that MRSA accounts for only 8 percent of hospital infections.

These new facts discredit the CDC's official 1.7 million estimate. CDC spokeswoman Nicole Coffin admits "the number isn't perfect." In fact, it is an irresponsible guesstimate based on a sliver of 6-year-old (2002) data. The CDC researchers who came up with it complained that not having actual data 'complicated the problem.'

Numbers matter. Health conditions that affect the largest number of people generally command more research dollars and public attention."

McCaughey's column is compelling and points a very strong finger at the CDC to (1) provide up-to-date, accurate data on this (preventable!) epidemic and (2) increase the protocols to be in line with those of other countries who have eradicated the problem (as Europe has with MRSA screening). She also draws correlations to other government regulators, noting:

"It is common for government regulators to become soft on the industry they are supposed to regulate. A coziness develops. Federal Aviation Administration inspectors failed to insist on timely electrical systems inspections, say news reports. The same may be true at the CDC, where government administrators spend too much time listening to hospital executives and not enough time with grieving families."

The current statistics on hospital-acquired infections (HAIs) are already mind-numbing...but to think that there are far higher, and far more that we could be doing makes McCaughey's voice one of the most important in the fight on preventable medical errors.

 Full piece located here. A transcript of McCaughey's address to Congress can be downloaded here (PDF).

Health Grades' Report Cites 238,000+ Preventable Deaths, $8+ Billion In Preventable Costs

In their fifth annual Patient Safety in American Hospitals Study, Health Grades Inc., cites that errors in treatment resulted in 238,337 potentially preventable deaths of Medicare patients in the US, costing $8.8 billion.

HealthGrades Inc. analyzed over 41 million patient records for the study and found that approximately 3 percent of all Medicare patients suffered from some medical error-- which equates to about 1.1 million Patient Safety Incidents (PSIs) from 2004-2006. In the report, Health Grades describes medical errors as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim…[including] problems in practice, products, procedures, and systems."

There were 270,491 actual in hospital deaths that occurred among patients who developed one or more of 16 PSIs and the report states, "Using previous research, we calculated that 238,337 were attributable to patient safety incidents and potentially preventable."

In a prepared statement, HealthGrades' chief medical officer and primary author of the study, Dr. Samantha Collier, said "While many U.S. hospitals have taken extensive action to prevent medical errors, the prevalence of likely preventable patient safety incidents is taking a costly toll on our health care systems -- in both lives and dollars", she continues, "HealthGrades has documented in numerous studies the significant and largely unchanging gap between top-performing and poor-performing hospitals. It is imperative that hospitals recognize the benchmarks set by the Distinguished Hospitals for Patient Safety are achievable and associated with higher safety and markedly lower cost."

Starting October 1st, the federal Centers for Medicare and Medicaid Services will stop reimbursing hospitals for the treatment of eight major preventable errors, including objects left in the body after surgery and certain kinds of post-surgical infections. As we covered recently, many insurance agencies have already stopped reimbursing for such errors.

Full report by Health Grades is located here (PDF).

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