The results of a recent study indicated adverse events remain disturbingly common for hospitalized patients, with 24% of admissions resulting in at least one adverse event that caused harm. Eight percent experienced a serious, life-threatening, or fatal adverse event. The results were derived from a random sample of 2,809 hospital admissions from 11 Massachusetts hospitals in 2018.1
The research shows adverse events are too common despite decades of attention from the healthcare community, says David W. Bates, MD, lead study author and professor of internal medicine at Harvard Medical School.
“Those data overall suggest that safety is still very clearly an important issue and that organizations need to be working on this,” Bates says.
Adverse drug events accounted for many of the incidents. Of the 978 adverse events tracked, 39% were adverse drug events, 30% were surgery-related, 15% were patient care events, and 12% were hospital-associated infections.
Surgical and procedural adverse events were especially likely to result in serious harm, and the patient care events were most likely to be preventable, Bates says. Overall, 23% of the adverse events were judged to be preventable, and 32% had a serious or higher clinical severity.
Bates says the research indicates previous efforts at reducing adverse events may have been hindered by the way data were collected. Current technology may be better at detecting adverse events by using electronic tools to scan medical records.
“We have not made as big a difference as we would like, and the rates of harm continue to be too high. I think we’ve perhaps focused more than is desirable on error reports and not enough on the actual harm that occurs,” Bates explains. “In the past, it wasn’t possible, practically speaking, to measure exactly how much harm you’re having in a variety of areas. But that is possible today.”
Focus on Actual Harm
Bates suggests shifting from looking at errors to focusing on the actual harm that occurs. Tracking that harm makes it possible to see patterns of a certain type of adverse event, like hospital-acquired infections.
“If you’re having a lot of catheter-associated UTIs, you want to know that so that you can work a little harder on that particular area because there are good solutions for nearly all these types of events,” Bates says. “One hard thing for institutions and for risk managers is deciding ‘Which thing should I work on now?’ There are so many possibilities in terms of what to work on.”
Response to the research has been favorable, Bates says, including some suggestions that hospital leadership has not paid as much attention to adverse events as it should have, especially in recent years.
“I think that’s true. COVID just caused so many issues and diverted so much attention that many other things could not be tracked as closely,” Bates notes. “I think safety is one of those things.”
Adverse events can be prevented by taking advantage of many of the technological improvements in recent years, as well as adhering to known best practices. For adverse drug events, Bates notes there are better tools in terms of medication-related decision support that can be used. For falls and pressure ulcers, new smart beds can reduce those rates.
“For hospital-acquired infections, often the issue is just how well you adhere to the various bundles that are focused on trying to reduce those types of infections,” Bates says. “If you know where your rates are high, that can help you think about where to focus.”
REFERENCE
- Bates DW, Levine DM, Salmasian H, et al. The safety of inpatient health care. N Engl J Med 2023;388: 142-153.
SOURCE
- David W. Bates, MD, Professor of Internal Medicine, Harvard Medical School, Boston. Phone: (617) 732-7063. Email: dbates@bwh.harvard.edu.