1 Million Medicare Patients Experience Medical Errors

Nearly one million patient safety incidents occurred among Medicare patients in 2009, a figure that matches what happened in the years 2006, 2007 and 2008.

According to HealthGrades, an independent healthcare ratings organization, errors cost the federal Medicare program nearly $8.9 billion and resulted in 96,402 potentially preventable deaths from 2006 through 2008.

Medicare patients who experienced one or more of the 15 patient safety events had approximately a one-in-10 chance of dying as a result of an event.

The seventh annual HealthGrades Patient Safety in American Hospitals study, which evaluated 39.5 million hospitalization records from the nation’s nearly 5,000 nonfederal hospitals using indicators developed by the federal Agency for Healthcare Research and Quality, tracks trends in a range of patient safety incidents and identifies those hospitals that are in the top 5 percent in the nation.

Patients at hospitals in the top 5 percent experienced 43 percent fewer patient safety incidents, on average, compared to poorly performing hospitals. If all hospitals performed at this level, 218,572 patient safety incidents and 22,590 deaths could potentially have been avoided, saving $2.0 billion from 2006 through 2008.

“This annual study serves the twin goals of documenting the state of patient safety for hospitals to benchmark against, and providing individuals with objective information with which to evaluate local hospitals,” said Rick May, MD, a vice president at HealthGrades and co-author of the study. “It is disheartening, however, to see that the numbers have not changed since last year’s study and, in fact, certain patient safety incidents, such as post-operative sepsis, are on the rise.”

Some highlights from the study:

• Large Safety Gaps Identified Between Top and Bottom Performing Hospitals: Patients treated at top-performing hospitals had, on average, a 43 percent lower chance of experiencing one or more medical errors compared to the poorest-performing hospitals.
• Less Improvement Seen Among Most Common Events: Six patient safety indicators showed improvement while eight indicators worsened in 2008 compared to 2006. Some of the most common and most serious indicators worsened, accounting for 78.94 percent of the total patient safety incidents studied. These include decubitus ulcer (bed sores), iatrogenic pneumothorax (collapsed lung), post-operative hip fracture, post-operative physiologic and metabolic derangements, post-operative pulmonary embolism (potentially fatal blood clots forming in the lungs) or deep vein thrombosis (blood clots in the legs), post-operative sepsis, and transfusion reaction.
• Most Common Patient Safety Incidents: The patient safety incidents with the highest incidence rates are, along with the event rates per 1,000: failure to rescue (92.71), decubitus ulcer (36.05), post-operative respiratory failure (17.52) and post-operative sepsis (16.53).

A full copy of the report and complete methodology is available at http://www.healthgrades.com/research.