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National Healthcare Quality Report, 2009 | ||||||||||
Chapter 3. Patient SafetyThe Institute of Medicine (IOM) defines patient safety as "freedom from accidental injury due to medical care or medical errors."1 In 1999, the IOM published To Err Is Human: Building a Safer Health System, which called for a national effort to reduce medical errors and improve patient safety.1 Central to this effort is the ability to measure and track adverse events. Measuring patient safety is complicated by difficulties in assessing and ensuring the systematic reporting of medical errors and adverse events. All too often, adverse event reporting systems are laborious and cumbersome. Health care providers may also fear that if they participate in the analysis of medical errors or patient care processes, the findings may be used against them in court or harm their professional reputations. Many factors limit the ability to aggregate data in sufficient numbers to rapidly identify prevalent risks and hazards in the delivery of patient care, their underlying causes, and practices that are most effective in mitigating them. These include difficulties aggregating and sharing data confidentially across facilities or State lines. Despite these limitations, a better picture of patient safety is emerging. Progress has been made in recent years in raising awareness, developing reporting systems, and establishing national data collection standards. Examining patient safety using a combination of administrative data, medical record abstraction, spontaneous adverse event reports, and patient surveys allows a more robust understanding of what is improving and what is not. Still, data remain incomplete for a comprehensive national assessment of patient safety.2 ImportanceMortality
Cost
MeasuresThis year's patient safety chapter highlights four core measures and seven additional measures related to health care-associated infections (HAIs), surgical complications, other complications of hospital care, and complications of medications: Core measures are:
Additional noncore measures include:
FindingsHealth Care-Associated InfectionsInfections acquired during hospital care (nosocomial infections) are one of the most serious patient safety concerns. They are the most common complication of hospital care.4 An estimated 1.7 million HAIs occur each year in hospitals, leading to about 100,000 deaths. The most common infections are urinary tract, surgical site, and bloodstream infections.5 A specific medical error cannot be identified in most cases of HAIs. However, better application of evidence-based preventive measures can reduce rates of HAIs within an institution. Such measures include using urinary catheters only when absolutely needed and administering prophylactic antibiotics before surgery at the right time. Outcome: Catheter-Associated Urinary Tract InfectionsThe urinary tract is a common site of HAI. Urinary catheter use and specific comorbid conditions can increase the risk of developing a UTI. Approximately 40% of all HAIs are attributed to catheter-associated UTIs.6 Figure 3.1. Adult Medicare surgery patients with postoperative catheter-associated urinary tract infection, overall and by age, 2005-2007 Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System (MPSMS), 2005-2007.
Prevention: Appropriate Timing of Antibiotics Among Surgical PatientsWound infection following surgery is a common HAI. Hospitals can reduce the risk of surgical site infection by making sure patients get the right antibiotics at the right time on the day of their surgery. Surgery patients who get antibiotics within the hour before their operation are less likely to get wound infections than those who do not. Getting an antibiotic earlier or after surgery begins is not as effective. However, taking these antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects, such as antibiotic resistance and serious types of diarrhea. Among adult Medicare patients having surgery, the National Healthcare Quality Report (NHQR) tracks receipt of antibiotics within 1 hour prior to surgical incision, discontinuation of antibiotics within 24 hours after end of surgery, and a composite of these two measures. Figure 3.2. Adult surgery patients who received appropriate timing of antibiotics: Overall composite, by age, 2005-2007 Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007.
Figure 3.3. State variation: Adult surgery patients who received appropriate timing of antibiotics, 2007 Key: Best quartile indicates States with highest rates of adult surgery patients who received appropriate timing of antibiotics; worst quartile indicates States with lowest rates.
Outcome: Postoperative SepsisSepsis, a severe bloodstream infection, can occur after surgery. Rates can be reduced by giving patients appropriate prophylactic antibiotics 1 hour prior to surgical incision. Figure 3.4. Postoperative sepsis after an operating room procedure per 1,000 elective surgery discharges, adults age 18 and over, 2004-2006 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004-2006.
Surgical CareAdverse health events can occur during episodes of care, especially during and soon after surgery. Although some events may be related to a patient's underlying condition, many can be avoided if appropriate care is provided. Outcome: Postoperative Care CompositeComplications after surgery may include, but are not limited to, pneumonia and blood clots. Figure 3.5. Composite measure: Adult Medicare surgery patients with postoperative complications (postoperative pneumonia or venous thromboembolic event), 2002-2007 Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System (MPSMS), 2002-2007.
Outcome: Postoperative Respiratory FailureRespiratory failure is not uncommon after surgery and may necessitate reintubation or prolonged mechanical ventilation. Causes include oversedation, exacerbation of underlying cardiovascular or respiratory conditions, and ventilator-associated pneumonia. Although some cases of respiratory failure cannot be prevented, closer attention to risk factors can reduce rates within an institution. Figure 3.6. Postoperative respiratory failure per 1,000 elective surgery discharges after an operating room procedure, adults age 18 and over, 2004-2006 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004-2006.
Figure 3.7. Postoperative respiratory failure per 1,000 elective surgery discharges after an operating room procedure, children under age 18, 2004-2006 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004-2006.
Other Complications of Hospital CareBesides surgery, other types of care delivered in hospitals can place patients at risk for injury or death. Outcome: Adverse Events Associated With Central Venous CathetersPatients who require a CVC to be inserted into or from the great vessels leading to the heart tend to be severely ill. However, the placement and use of these catheters can result in infections and other complications. Figure 3.8. Bloodstream infections or mechanical adverse events associated with central venous catheter placement: Overall composite, by age, 2005-2007 Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System (MPSMS), 2005-2007.
Outcome: Accidental Puncture or LacerationAdverse events, including the nicking or cutting of bodily organs and blood vessels, are possible during any operation or procedure. This may be especially true in emergent situations, when, according to an expert panel review, some of these occurrences are not preventable. Puncture or laceration can lead to serious complications.7 Figure 3.9. Accidental puncture or laceration during procedure per 1,000 discharges, adults age 18 and over, 2004-2006 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004-2006.
Outcome: Deaths Following Complications of CareMany complications that arise during hospital stays cannot be prevented. However, rapid identification and aggressive treatment of complications may prevent these complications from leading to death. Deaths following complications of care, also called "failure to rescue," is an indicator that tracks deaths among patients whose hospitalizations are complicated by pneumonia, thromboembolic events, sepsis, acute renal failure, gastrointestinal bleeding or acute ulcer, shock, or cardiac arrest.7 Figure 3.10. Deaths per 1,000 discharges with complications potentially resulting from care (failure to rescue), adults ages 18-74, by insurance, 2004-2006 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004-2006.
Complications of MedicationsComplications of medications are common safety problems. Some, but not all, adverse drug events may be related to misuse of medication. However, prescribing medications that are inappropriate for a specific population may increase the risk of adverse drug events. Outcome: Adverse Drug Events in the HospitalSome medications used in hospitals can cause serious complications. The Medicare Patient Safety Monitoring System tracks a number of adverse drug events, including serious bleeding associated with intravenous heparin, low-molecular-weight heparin, or warfarin, and hypoglycemia associated with insulin or oral hypoglycemics. Figure 3.11. Hospitalized Medicare patients with adverse drug events, 2004-2007 Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System (MPSMS), 2004-2007.
Outcome: Potentially Inappropriate Prescription Medications for Adults Age 65 and OverSome drugs are considered potentially harmful for older patients but nevertheless were prescribed to them.8,iii Figure 3.12. Adults age 65 and over who received potentially inappropriate prescription medications in the calendar year, 2002-2006 Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.
Focus on Patient Safety CultureHigh-reliability organizations that achieve low rates of adverse events establish "cultures of safety." A culture of safety is characterized by shared dedication to making work safe, blame-free reporting and communication about error, collaboration and teamwork across disciplines, and adequate resources to prevent adverse events. AHRQ developed the Hospital Survey on Patient Safety Culture to help hospitals assess the culture of safety in their facilities. AHRQ began producing comparative database reports in 2007 to help hospitals assess their performance relative to similar institutions. In this NHQR, we present data from the Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report.9 This report is based on survey responses collected in 2008 from nearly 200,000 hospital staff in 622 hospitals. The average hospital response rate was 52%, with an average of 316 completed surveys per hospital. Most hospitals administered paper surveys rather than Web-based surveys. In addition, most hospitals administered the survey to all staff or a sample of all staff from all hospital departments. Nurses accounted for more than one-third of respondents, followed by "other." More than three-quarters of respondents had direct interaction with patients. Results are presented for the 12 patient safety culture composites addressed in the survey, expressed as average percent positive response. Percent positive refers to the percentage of responses that agree or strongly agree with a positively worded item (e.g., "People support one another in this work area") and the percentage that disagree or disagree strongly with a negatively worded item (e.g., "We have safety problems in this work area"). Hospitals contributing data to the comparative database mirror the population of U.S. hospitals as a whole, but participation is entirely voluntary. Thus, findings may not be generalizable to all types of facilities. Figure 3.13. Patient safety culture composites, all hospitals, 2008 Source: Agency for Healthcare Research and Quality, Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report.
References1. Kohn L, Corrigan J, Donaldson M, eds. To err is human: building a safer health system. Washington, DC: Institute of Medicine, Committee on Quality of Health Care in America; 2000. 2. Aspden P, Corrigan J, Wolcott J, et al. Patient safety: achieving a new standard of care. Washington, DC: Institute of Medicine, Committee on Data Standards for Patient Safety; 2004. 3. Encinosa WE, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients. Health Serv Res 2008 Dec;43(6):2067-85. Epub 2008 Jul 25. 4. Thomas EJ, Studdert DM, HR B, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71 5. Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Pub Hlth Rep 2007;122:160-6. 6. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med 2000 Mar 13;160(5):678-82. 7. Guide to Patient Safety Indicators Version 3.1. Rockville, MD: Agency for Healthcare Research and Quality; 2003. Available at: http://www.qualityindicators.ahrq.gov/downloads/psi/word/psi_guide_v31.doc. Accessed on November 17, 2009. 8. Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA 2001 Dec 12;286(22):2823-9. 9. Hospital Survey on Patient Safety Culture: 2009 comparative database report. Rockville, MD: Agency for Healthcare Research and Quality; 2009. AHRQ Publication No. 09-0030. Available at: http://www.ahrq.gov/qual/hospsurvey09/. Accessed on June 15, 2009 i The States are Delaware, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, North Carolina, South Carolina, South Dakota, Vermont, and Wisconsin. Return to Contents
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