HCLF: Adverse events higher than previously reported

CHICAGO—Adverse events in hospitals may be ten times greater than previously measured, according to research conducted by David C. Classen, MD, MS, CMIO of Pascal Metrics and assistant professor of the department of medicine at the University of Utah, who spoke during the Healthcare Leadership Forum on Nov. 14.

Traditional reporting of errors, incidents or events does not reliably occur in the best of cultures in healthcare, he said. A report from the Office of the Inspector General (OIG) found that only 1 percent of adverse events are reported. Voluntary methods underestimate events and concentrate on what is interpreted as being preventable, Classen said.

“The best evidence we have is inpatient focused, particularly on medication safety. Beyond that, the evidence evaporates pretty quickly.” Other industries can help, he said, and the field is a critical area for more research and development.

“Overall, the newest studies of patient safety should not be used to congratulate ourselves on how we’re doing but raise concerns that we haven’t made more improvements.” Those reports estimate 200,000 to 400,000 patient deaths due to medical errors every year.

That OIG report indicates that one-third of Medicare patients are suffering patient safety incidents as part of their hospitalizations. “Probably 180,000 deaths in Medicare patients alone every year are related to medication errors in the hospital. That’s double what the Institute of Medicine reported in 1999.” This is happening even in hospitals with very sophisticated health IT systems, he said. “If it’s this bad in these hands, it’s probably pretty bad in other facilities.”

Studies also have shown that patients who experience one complication in a hospital have an increased risk of 30 percent of experiencing another complication, he said. That more than doubles the risk of death, increases length of stay and increases the cost of hospitalization. “We’re also now finding out that it markedly increases risk of readmission—by factor of 3. That risk doesn’t stop at 30 days either– it lasts for one year.” That’s a big deal, Classen said, because it increases the use of ambulatory resource use for up to 6 months.

Given all these disturbing figures, Classen pointed out that “the state of patient safety won’t improve until we improve our measurement.”

He said that about 10 years ago, the airline industry started having airplanes send data from the plane back to an operation center every 30 seconds. Those at the center evaluate the data rather than the flight crew. “We’re just now beginning to replicate that in healthcare.”

For now, the process is lengthy manual reviews, he said. “The more you look the more you find. We haven’t made much progress.” Hospitals have siloes for IT, people, process, organizational management and more and just added another silo with EHRs, he said. “We need to start leveraging data from EHRs to drive safety.”

There isn’t a lot of evidence, Classen said, but “we’re moving from retrospective risk management to a prospective system. We’re just at the start of the journey.”

The Healthcare Leadership Forum was sponsored by ClinicalKey and presented by Clinical Innovation + Technology.