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Adverse events in hospitals 10 times more common than known

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Adverse events in hospitals 10 times more common than known

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A study released in early April 2011 compared three methods of detecting adverse events in hospitals. The first is voluntary reporting. This method depends on healthcare workers coming forward and admitting that an error has occurred. At a minimum, they are expected to report what are called sentinel events: any unanticipated event in a health care setting resulting in serious injury or death, not related to a natural course of the patient’s illness. The study found that there was very poor compliance with voluntary reporting. In other words, healthcare workers did not reveal their errors.

As a result of the focus on sentinel events, many states have put mandatory reporting of these events into place. The government defined “hospital acquired conditions” for which Medicare and Medicaid will not pay. Here is what the government says:

Hospital Acquired Conditions (HAC) are serious conditions that patients get during an inpatient hospital stay. If hospitals follow proper procedures, patients are less likely to get these conditions. Medicare doesn’t pay for any of these conditions, and patients can’t be billed for them, if they got them while in the hospital. Medicare will only pay for these conditions if patients already had them when they were admitted to the hospital.

These are the current HACs. The first 3 are quite common, according to newly released data:

  • Catheter associated urinary tract infection
  • Falls and trauma
  • Vascular catheter associated infection

    Of these 3, Med League receives the most calls about cases involving falls and trauma.

    Other HACs include

  • Manifestations of poor glycemic control (evidence of unstable blood sugar)
  • Blood incompatibility (giving the wrong blood transfusion to a patient)
  • Stage III and IV pressure ulcers (stage IIIs sores are deep pressures sores to just above the muscle level. Stage IV sores expose muscle or bone.)
  • Air embolism (bubble of air in the blood)
  • Retained object after surgery such as a dressing or instrument left behind

You can see how well your hospital is doing on the HACs compared to other hospitals at the link below.
The file in the Downloads section at this link shows how often HACs occurred for Medicare fee-for-service claims from October 2008 through June 2010. The measures are expressed as the number of HACs per 1,000 discharges; they are not adjusted for hospitals’ patient population (case-mix).

Source: http://www.cms.gov/HospitalQualityInits/06_HACPost.asp
Study: Classen, D and others, Global trigger tool shows that adverse events in hospitals may be ten times greater than previously measured, Health Affairs April 2011

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