Hospital Patient Safety Report Provides Data, Analysis, and Recommendations

BALTIMORE (June 13, 2013) – The Office of Health Care Quality (OHCQ) has released its annual Hospital Patient Safety Report, which analyzes the serious adverse events reported by Maryland hospitals in Fiscal Year 2012.

 In Fiscal Year 2012, hospitals submitted 286 reports of Level 1 adverse events, down from 348 reports in FY 2011. Level 1 adverse events are unexpected occurrences related to an individual's medical treatment and not related to the natural course of the patient's illness or underlying condition that results in death or a serious disability.  

 Key findings of the report include:

  • Acute care hospitals account for 67 percent of all Maryland licensed hospitals and report 94 percent of all adverse events. Hospitals with more than 100 beds reported an average of 4.8 adverse events each, while those with less than 100 beds reported an average of 0.9 Level 1 events each.
  • As with previous years, pressure ulcers and falls continue to make up the majority of the reports received, with 98 and 86 reports, respectively. These two types of events account for nearly two-thirds of all reports in FY12.
  • The increase in suicides, from five in FY 2011 to 16 in FY 2012, represents a troubling trend in reported events. Nine of these occurred outside the hospital shortly after discharge from emergency departments and inpatient behavioral health units.
  • The post-surgical retention of foreign bodies decreased from 17 in FY 2011 to 13 in FY12, with most of the reported events occurring during emergency abdominal procedures in obese patients.
  • In FY 2012, there were 12 reports of medication errors leading to death or serious disability, including one each untreated hypoglycemia and anticoagulation events. Five of the reported medication errors involved overdoses of sedatives, pain medications, and the anesthetic agent propofol.
  • There were some commonalities among poor quality root cause analyses submitted to OHCQ, including: a focus on what happened rather than why; a lack of identified causality and defined root causes; and ineffective interventions aimed at the bedside, with no monitoring to determine the outcomes of the interventions.

These key findings have informed recommendations contained in the report. The recommendations include:

  • Hospitals should consider asking alert and oriented patients to sign an informed declination of services when the patients refuse basic interventions to prevent falls and pressure ulcers.
  • Assessments of suicide risk in patients about to be discharged should include an assessment of hazards and the availability of weapons in the home.
  • Each suicide attempt should be considered predictive of future behavior. Inpatients with suicidal intent should be on one-to-one or arms-length supervision.
  • Hospitals should implement evidence based assessments, improved safety protocols, and maintain a keen awareness of environmental hazards.
  • Hospitals should proactively address the contributing factors that are common in medication errors, including communication failures, lack of effective medication reconciliation, dosage calculation failures, and complacency.
  • Root cause analysis teams should pay more attention to the role of staff supervision (or the lack thereof) in the adverse events. Many adverse events could be averted with timely interventions.
  • Hospital leaders should participate in the root cause analysis process to provide valuable insight into the challenges faced by patients and by front line staff.  Leadership participation also lets the staff know that administration supports the root cause analysis process. Most adverse events require some analysis of latent issues that hospital leadership is in a better position to rectify.

OHCQ works with Maryland hospitals and the Maryland Patient Safety Center to promote these and other recommendations.

To view the full Fiscal Year 2012 Hospital Patient Safety Report, visit http://dhmh.maryland.gov/ohcq/docs/Reports/FY2012%20Patient%20Safety%20Report%20FINAL.pdf.

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