Despite efforts to improve patient safety over the last decade, a quarter of Medicare patients continue to experience harm and complications during hospital stays, according to a new report from HHS' Office of Inspector General (OIG).

Cheat sheet: Hospital-Acquired Condition Reduction Program

Report details and key findings

For the report, researchers reviewed a sample of 770 Medicare patients, out of approximately 1 million, who received inpatient care at 629 hospitals nationwide in October 2018. Overall, 25% experienced either an adverse or temporary harm event during their hospital stay.

In total, 12% of patients experienced adverse harm events, which resulted in longer hospital stays, lifesaving interventions, permanent harm, or death. Of these events, 74% resulted in longer hospital stays, while 10% resulted in death. In total, around 1.4% of all hospitalized Medicare patients, or an estimated 14,800 people, died due to adverse harm events during the study period.

In comparison, 13% of patients experienced temporary harm events, which required intervention but did not prolong their hospital stay or require lifesaving measures. However, these events were sometimes serious and could have caused further harm without timely intervention.

Both the adverse and temporary harm events were associated with complications from medication, patient care, procedures or surgeries, and hospital-acquired infections. Common harm events include hypotension, pressure injuries, excessive bleeding, and respiratory infections.

In addition, 23% of patients who experienced harm events saw additional Medicare costs, for both deductibles and co-payments. Among some Medicare patients, the additional cost of care was more than $40,000. "Combined, we estimated the cost for all events to be in the hundreds of millions of dollars for October 2018," OIG wrote.

According to the report, many of these events—including 45% of adverse harm events and 40% of temporary harm events—were preventable. In addition, seven out of 11 adverse events that resulted in death were determined to be preventable.

These preventable events were often associated with substandard or inadequate care, including unnecessarily aggressive pain management regimens after surgery or unnecessary delays in scheduling surgeries.

For example, the report referenced a case study of a patient who required surgery to remove dead tissue from their small intestine. The surgery was delayed for five days, which "led to a cascade of harms that included worsening of the small intestine, contamination of the abdomen with pus, septic shock with an associated kidney injury, and delirium."

Commentary

Leah Binder, president and CEO of the Leapfrog Group, which recently released its 2022 hospital safety grades, said the report's findings were "outrageous."

"None of us would drive a vehicle or check into a hotel if we thought we had a one in four chance of being harmed from the experience," she said.

According to OIG, the prevalence of patient harm events among Medicare beneficiaries has largely remained the same since they were last analyzed by the organization in 2008. Back then, 27% of Medicare patients experienced a harmful event while hospitalized.

With minimal improvement over a ten-year period, even with new patient safety efforts and incentives, OIG has called for CMS and the Agency for Healthcare Research and Quality (AHRQ) to renew their focus on patient safety and add new policies to reduce harm.

In particular, OIG recommended that CMS add more hospital-acquired conditions (HACs) to its harm prevention incentive policies. Currently, "the policies use narrowly scoped lists of HACs and employ specific criteria for counting harm events," which limits their effectiveness in promoting patient safety, OIG wrote in its report. In fact, of the harm events identified in the report, only 5% were on CMS' HAC Reduction Program list, and only 2% were on the Deficit Reduction Act HAC list.

In addition, OIG recommended AHRQ update its Quality Strategic Plans and invest in new strategies, including research, tools, and projects, to prevent common patient harm events in hospitals.

"We still have a significant way to go in terms of improving patient safety," said Amy Ashcraft, a deputy regional inspector general. (Clark, MedPage Today, 5/13; Alltucker, USA Today, 5/12; Cass, Becker's Hospital Review, 5/12; Devereaux, Modern Healthcare, 5/13; HHS OIG report, 5/12)