Nearly 1 in 7 Hospitalized Medicare Patients Experience Adverse Events

November 16, 2010

November 16, 2010 — An estimated 13.5% of hospitalized Medicare patients experience adverse events ranging from pulmonary embolisms to wrong-body-part surgery, and such events result in the death of 1.5% of all hospitalized Medicare patients, according to a new study released today by the Office of Inspector General (OIG) in the US Department of Health and Human Services.

Another 13.5% of hospitalized Medicare patients experience minor adverse events such as excessive bleeding and prolonged nausea that cause temporary harm.

Of the major and minor adverse events combined, 44% are preventable, the OIG reports. That finding points to the potential to save not only a significant number of lives but also dollars, because all these events accounted for an estimated $4.4 billion in Medicare inpatient spending in fiscal year 2009.

The OIG studied 780 Medicare patients who were discharged from hospitals in October 2008. Physician reviewers determined whether the patients had experienced an inpatient adverse event, and whether it appeared on 1 of 3 lists. The first is the list of serious reportable incidents — often called "never events," because they should never happen in a hospital — from the National Quality Forum. These events include death or serious disability associated with medication errors, contaminated devices, falls, and other adverse events.

The second list is the Medicare Hospital-Acquired Conditions list — a litany of pressure ulcers, surgical-site infections, glycemic crises, and the like. Medicare will not pay for treatment necessitated by these conditions.

The third list, created by the National Coordinating Council for Medication Error Reporting and Prevention, categorizes adverse events based on the level of harm. The OIG limits itself to the top 4 levels: a prolonged hospital stay, permanent harm, the necessity for a life-sustaining intervention, and death.

Of the 780 patients in the study, 0.6% experienced an adverse event on the National Quality Forum list, 1% an adverse event on the Medicare Hospital-Acquired Conditions list, and 13.1% an adverse event on the National Coordinating Council for Medication Error Reporting and Prevention list. Twelve patients, or 1.5%, died as a result of an adverse event.

On the basis of these findings, the OIG recommends that the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality broaden their definition of adverse events and work harder to identify them. In addition, the Centers for Medicare and Medicaid Services should expand the list of adverse events for which it will not foot the bill and should look for opportunities to hold hospitals accountable for adopting evidence-based practice guidelines, according to the OIG.


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