OVERVIEW

Delivering care that is safe, high quality, patient-centered and error-free is a guiding aspiration for many, if not all, U.S. hospitals and health systems. But preventable medical errors, adverse events and never events still occur at an alarming rate.

A commonly cited report from 2016 puts medical error as the third leading cause of death in the U.S. (Makary & Daniel, 2016), with 251,000 deaths attributed to medical error annually. Another report puts the number of American deaths each year from medical error significantly higher at up to 440,000 (James, 2013). While far too many medical errors prove to have fatal consequences, many errors occur that do not result in death. One report estimates that 1.7% of all hospital admissions result in medical error (Shreve, et al., 2010).

The financial consequences of unsafe care and treating the injuries that result from errors is no small burden. It is estimated that medical errors cost the U.S. economy upwards of $20.8 billion annually (Perez, 2016), with the average cost of each incident of preventable harm at over $58,000 per injury (Bernazzani, 2016). The $20.8 billion figure accounts for the costs directly associated with care and services, as well as costs resulting from increased mortality rates and missed work days that result in lost productivity. Payouts for catastrophic medical malpractice – those that are $1 million or above – are estimated at $1.4 billion per year (Corrigan, Wakeam, Gandhi, & Leape, 2015).

Calls for increased transparency, greater accountability and the financial repercussions attached to not delivering the highest quality care have placed strains on healthcare organizations across the United States. Hospitals and health systems have become increasingly committed to strengthening patient safety and pursuing a culture of quality, efficient care through the gathering and analysis of adverse event data. This paper highlights the five most common safety events reported by Quantros’ hospital and health system customers in 2016, and explains the ways healthcare professionals are harnessing these insights and data to reduce adverse events and making safer, higher quality care a reality.

SAFETY EVENT #5: SKIN INTEGRITY

Skin integrity events were the fifth most reported type of event in Quantros Safety Event Manager (SEM) in 2016, with 40,659 events reported. This comprised almost 6% of all safety events reported in SEM in 2016.

About 48.6% of the skin integrity events reported were from facilities located in the South, while another 23.6% of the events reported were from facilities located in the West. While 26.9% of the facilities that reported events were located in the Midwest, only 8.2% of the total events reported occurred in those facilities. See the image below for the geographic breakdown of facilities reporting skin integrity events and the number of events reported.

Skin integrity events include safety issues that impact the skin, including pressure wounds, accidental needle sticks or sharps injuries, burns, bruises, and cuts or lacerations among others. Diabetic or vascular ulcers and non-healing wounds also fall into this category.

The reported skin integrity events range in severity, from a circumstance that had the capacity to cause error (but no error occurred) to temporary and permanent harm, to an error resulting in death. The majority of the skin integrity events reported – 15,804 of them – are classified as Category E, meaning an error occurred and the patient experienced temporary harm and intervention was required. Of the skin integrity events reported in 2016, 44.8% resulted in no harm (Categories B-D), 44% resulted in temporary or permanent harm (Categories E-H) and one event – 0.002% – resulted in death to the patient (Category I).

Pressure injuries, previously known as pressure ulcers, are the result of prolonged pressure being applied to a body part and are a common hospital-acquired safety event. They are reportedly the fourth leading preventable medical error in the U.S (Pressure Ulcer Never Event, 2017). According to the Agency for Healthcare Research and Quality, more than 2.5 million people in the U.S. develop pressure injuries annually, costing between $9.1 and $11.6 billion each year (Agency for Healthcare Research and Quality, 2014). The Centers for Medicare and Medicaid (CMS) have estimated that each pressure injury event that affects patients adds over $43,000 in costs to a hospital stay (Agency for Healthcare Research and Quality, 2014). Because pressure injuries that occur after admission are categorized as a never event, CMS does not provide additional reimbursement to hospitals for patients who acquired the pressure injury during their hospital stay.

Sharps injuries are an event that affect healthcare professionals as well as patients. The Centers for Disease Control and Prevention (CDC) approximates that over 1,000 sharps-related injuries occur per day among healthcare workers in the U.S., resulting in 385,000 injuries each year (Centers for Disease Control and Prevention, 2015). One estimate puts the cost of sharps events at $3,000 per injury, meaning over $1 billion each year is spent on sharps injuries (Yi, 2016).

Many organizations have created guidelines and hospitals have implemented proven processes to prevent skin integrity adverse events from occurring. AHRQ recommends assessing patients’ skin and hydration levels at admission and continuing to assess patients each day, as well as guidelines for repositioning patients every 1 to 2 hours (Agency for Healthcare Research and Quality). The monitoring and daily assessments aim to evaluate the risks and help in prevention of pressure injuries, lesions, and other skin integrity issues. Along with these recommendations, AHRQ provides access to the Braden Scale for Predicting Pressure Sore Risk, which is a scoring system to evaluate the patient’s risk of developing a pressure injury, and other tools that may help in assessment and developing protocols. Staff education and awareness of the risks are considered crucial factors in the prevention of adverse events and maintenance of skin integrity. By educating their staff on learning to distinguish skin injuries and implementing a “Countdown to Zero” program, the University of Chicago Medicine reduced the number of preventable skin injuries at the medical center (Infection Control Today, 2017).

The American College of Surgeons released recommendations to prevent sharps injuries, as well as rips in surgical gloves that may expose healthcare personnel to infection. Recommendations include doubling up on surgical gloves, using blunt-tip suture needles, creating a designated area (like a towel) for the pickup and release of sharps so hands do not come in direct contact with the instruments, and finally adopting the use of engineered sharps injury prevention (ESIP) mechanical devices (American College of Surgeons, 2016).

SAFETY EVENT #4: LABORATORY EVENTS

The fourth most commonly reported type of event in 2016 were laboratory events. There were 56,202 Laboratory events reported, accounting for just over 8% of the total events recorded in SEM.

As with Skin Integrity events, the Southern region led the way with most facilities reporting the highest number of laboratory events. Two hundred thirty facilities in the South (40%) reported 19,580 events (34.9%). In the Midwest, the second highest number of facilities – 154 facilities (26.8%) – reported the third highest number of events: 12,764 events (22.8%).

Of those events reported in 2016, the vast majority – over 52% – fell into Category C Severity, meaning they did not cause harm. A total of 77.5% of the events reported fell into Categories B-D meaning they reached the patient but caused no harm. About 5% of the laboratory events recorded resulted in temporary or permanent harm (Categories E-H), and 3 events (0.005%) contributed to or resulted in the death of the patient (Category I).

Typically, laboratory events fall within three categories or natures : Pre-analytic issues (those events that occur before the test), analytic issues (issues during the test) and post-analytic issues (those that occur after the test). Pre-analytic issues include an unusable specimen – either due to contamination or insufficient quantity, the specimen is missing or delayed, or a specimen is sent to the incorrect lab. Analytic issues would be a contaminated culture or the wrong test, wrong time or frequency, and more. Events that occur in the post-analytic phase include a delay in patient notification, a result error or discrepancy, or a contradictory second opinion, among others.

Studies have found that the lion’s share of errors occur prior to testing – in the pre-analytic phases – with up to 75% of laboratory errors occurring before the test (Hammerling, 2012). The most common errors cited in the pre-analytic phase include specimen labeling errors, improperly collected samples, wrong blood in tube and missing specimens and subsequent redraws (Atwaru, Duen, Poczter, & Guigliano, 2016).

Pre-analytic laboratory errors can lead to increased costs due to quality assurance investigations, blood redraws, repeat testing and management oversight, costing a moderately-sized hospital upwards of $1 million each year (Kurec, 2016). One study looked at the average costs associated with common lab errors, such as missing specimens and wrong blood in tube, and estimated the cumulative cost of the errors over three months, to illustrate how minor errors can accrue to become costly issues for hospitals and health systems (Medscape, 2016). This study revealed that a specimen that is missing and later found costs $401.25 per error, which in turn costs $14,846.25 over three months. A missing specimen that is never found costs $583.72 per error and $20,430.20 over three months.

Source: Cost of Laboratory Errors a ‘Real Eye-Opener’ – Medscape – Sep 19, 2016.

An article in American Nurse Today gives advice on steps to take to prevent laboratory errors, including positively identifying the patient with multiple identifiers, avoiding blood-culture contamination by washing and drying hands and using sterile equipment, and not allowing unlabeled samples or specimens to leave the patient’s bedside (Proehl, 2016). A recent study focused on increased workflow monitoring, quality checks and, most importantly, staff awareness of the errors significantly decreased the amount of errors. The authors of the study noted that training alone was not enough to provoke satisfactory staff performance and stated, “It is vital to hold people accountable for their performance, and to put effective monitoring and evaluation systems in place” (Al Saleem & Al-Surimi, 2016). The result was a 25% reduction in errors the occurred during the pre-analytical stage.

SAFETY EVENT #3: ADMISSION/TRANSFER/DISCHARGE

With 75,455 events reported, incidents that take place during admission, transfer or discharge were the third most commonly reported event type in 2016 in SEM. These events represent just over 11% of the total events reported in 2016.

Once again, both the majority of the events reported and facilities reporting events were located in the Southern region of the U.S. A total of 225 facilities (39.5%) reported 41,764 events (55.4%). In the Northeast, the lowest number of facilities – 98 (17.2%) – reported the second most events, with 14,018 events reported (18.6%).

The bulk of the events – almost 63% – were those in which an error reached the patient but no harm was caused (Category C). Of the Admission/Transfer/Discharge events reported, over 58,000 or 77.4% were an event in which an error occurred but did not cause harm (Categories B-D). Categories E-H, in which temporary or permanent harm occurred, made up 4.2% of the reported events. The error either contributed to or resulted in death (Category I) in 52 of the events, or 0.07%.

Admission/Transfer/Discharge incidents may be reported due to delays, identification errors, or scheduling issues. Specifically, admission events include denial of admission, unplanned readmission, bed availability issues, missed appointments and more. Transfer incidents encompass incomplete handoffs, transfers to the wrong level of care, unscheduled transfers, ambulance or van in traffic accident, inadequate communication between providers or staff, or inadequate communication with patient, among others. Discharge events may include the patient leaving or absconding against medical advice, discharging the patient to the wrong person, the patient leaving before a physician assessment or triage completion, and more.

Hospital admissions, and by association, transfers and discharges have skyrocketed in the last 70 years. Between 1946 and 2013, admissions surged from 15.6 million people to 35.4 million for a 125.9% increase (Earl, 5 Statistics to Know About Hospital Admission Rates, 2015). While admissions are on the rise from seven decades ago, length of stay has decreased. In 1946, the average length of stay in nonfederal general hospitals was 9.1 days. In 2013, that number feel to 5.4 days (Earl, 5 Statistics About Hospital Capacity Over Time, 2015).

The Joint Commission has published a guide that provides recommendations on improving transitions of care, which it defines as “the movement of patients between health care practitioners, settings, and home as their condition and care needs change” (The Joint Commission, 2012). Root causes outlined by the report include breakdowns in communication, patient education, and accountability. The report details steps that healthcare personnel teams can take from the patient’s admission through their hospital stay, to create an effective transition of care. These steps include daily meetings, active sharing of knowledge with all involved in the patient’s care, confirmation of the patient’s needs at the next care setting, and timely follow-up and support after the patient leaves.

SAFETY EVENT #2: FALLS & SLIPS

Falls and slips were the second most commonly reported event in SEM in 2016. Falls and slips made up 11.5% of all events reported in 2016, with 78,627 events reported. A total of 937 facilities in the U.S. reported falls and slips, with the majority of facilities reporting (38.7%) and events reported (44.2%) located in the Southern region. The Midwest region had second highest number of facilities reporting these events (35%), but the lowest number of events reported (15.9%).

Most of the reported falls and slips (40.6%) fell within severity category D, meaning the error reached the patient and monitoring was required to confirm that no harm resulted from the event, and/or intervention was required to prevent harm. The clear majority of falls and slips reported – 57,322 or 72.9% – were those that resulted in no harm (Categories B-D). Temporary or permanent harm occurred in 14,468 reported events, or 18.4% (Categories E-H). Of the reported incidents, 19 events (0.02%) contributed to or resulted in death (Category I).

When a slip or fall is reported in SEM, it must first be characterized as an Adult Fall or Pediatric Fall. Then, causes are noted, such as whether the fall was accidental, due to physiological factors, whether the child was at play, whether it is a suspected intentional fall or other. Risk factors such as weakness or balance deficits, mobility limitations, cognitive impairments or others are reported. The reporter also may note what the patient was trying to do immediately prior to the fall and the condition of the floor surface, among other details.

The Joint Commission reports that falls result in injuries 30-50% of the time, necessitating additional treatment, and at times, increased lengths of stay (The Joint Commission, 2015). The report notes that a fall with injury can add 6.3 days to a hospital stay, and costs on average $14,000. Another study found that regardless of the degree of injury associated with the fall, acute inpatient falls meant a longer stay in the hospital (Dunne, Gaboury, & Ashe, 2014).

A report released by the American Hospital Association’s Health Research & Education Trust revealed that hospitals that had the most success in reducing patient falls shared two key elements: adequately measuring and analyzing the contributing factors, and addressing culture change to develop a culture of “zero falls” (Health Research & Educational Trust, 2016). The report noted that some organizations believed they understood and had already addressed the contributing factors, but those that measured and analyzed their results “were able to identify the contributing factors that mattered in their area and focus their time and resources on implementing solutions targeted to the critical few contributing factors that mattered in their area.” The results were a 62% reduction in the falls with injury rate and 35% reduction in the falls rate for the organizations that participated in the project.

SAFETY EVENT #1: MEDICATION

Medication events took the top position as the most reported event in SEM in 2016. Over 24,000 more medication events were reported than the second most reported event, falls & slips. Medication events made up 15.2% of all events reported in 2016 with 103,581 events reported.

The Southern region led the way again in both the number of facilities reporting – 304 (38.6% of the total facilities reporting) – and the total number of events reported – 42,616 (41.2% of the total events reported). The Midwest had the second most facilities reporting, but the fewest events reported.

As with many of the other voluntarily reported events in 2016, the majority of reported medication events (37.3%) fell within severity Category C – an error that reaches the patient but does not cause harm. The total amount of errors that did not cause harm (Categories B-D) was 70,050, representing 67.6% of the events reported. Errors that reached the patient and caused temporary or permanent harm (Categories E-H), totaled 8,921 events, or 8.6% of the events reported. Of the medication events reported, 38 (0.04%) had errors that contributed to or resulted in the death of the patient (Category I).

Medication events may fall into one of several categories of issues – patient injuries or complications, product or labeling issues, dispensing or administering issues, prescribing issues or best practices issues. Patient injuries or complications may include adverse drug reactions, allergies or suspected drug thefts, among others. Product or labeling issues could include incorrect directions on the medication label, the wrong product in the bottle, a loose cap, refill labeling incorrect, and more. Dispensing or administering issues could be a bagging error, check out error, a wrong dosage, an expired product, self-medication, or other errors. Prescribing issues include call-in errors, illegible orders, an incomplete order, and more. Best practices issues include delays, inadequate review of drug-related information, protocol or policy not followed, or patient perceived errors, among others.

One article estimates that preventable medication errors affect over 7 million patients and account for $21 billion each year across all care settings (da Silva & Krishnamurthy, 2016). The article also states that adverse drug events (ADEs) make up 1/3 of all hospital adverse events, and the average hospitalized patient can expect to experience at least one medication error per day. In addition to the economic burden, many patients must prolong their hospital stays due to medication errors. ADEs increase lengths of stay by 1.7-4.6 days (U.S. Department of Health and Human Services, Offices of Disease Prevention and Health Promotion, 2014).

Working to prevent medication errors must become an evolving and nimble process, as each year new medicines are developed, new uses are discovered for existing medicines, and the population ages and turns to medicine for treatment and prevention of illnesses. Improvements to communication and increased training are primary focuses for the eradication of medication errors, as well as reviewing the errors to learn from previous mistakes (da Silva & Krishnamurthy, 2016).

The World Health Organization (WHO) seeks to trim preventable medication-related errors by 50% with its Global Patient Safety Challenge on Medication Safety initiative (World Health Organization, 2017). WHO plans to use the Challenge as an outlet to provide guidance and recommend strategies that will aid in making the prescribing, dispensing, administering, monitoring and use of medication a virtually error-free process.

MAKING CARE SAFER

Preventable medical errors continue to plague the healthcare industry, to the point that medical error is among the top causes of American deaths. Those in healthcare face increasing pressure from their community, healthcare payers and regulatory entities to prevent adverse events and increase quality and safety performance. Financial burdens that arise from adverse events include a loss of reputation and market share, non-reimbursements hospital care and stay for services related to preventable errors and lawsuits related to the events. Many hospitals and health systems have implemented systems that gather, measure and analyze quality metrics related to patient safety and have developed strategies to monitor events in an effort to create an environment that promotes accountability, transparency and safety.

Organizations have made great progress in reducing preventable errors by focusing on increasing communication and sharing knowledge between caretakers and patients, measuring and analyzing events for future prevention, and ensuring those in the organization are aware of the errors and near misses. Incident reporting programs are a critical tool in ensuring healthcare organizations gather the data, are able to create actionable reports and gain the insights they need to understand areas for improvement and make changes to improve quality and safety.

Having the right tools in hand enables healthcare organizations to define trends, identify deficiencies and determine where resources need to be focused to make the most impact. Only by gaining a full understanding of the current safety landscape through the gathering of data and metrics can healthcare organizations achieve meaningful change to improve the quality of care.

REFERENCES


Quantros’ mission and vision is to deliver solutions that dynamically monitor risks, measure financial and clinical performance and enable the quality improvements that make care safer. As a trusted value-based partner, our Software-as-a-Service (SaaS) applications help thousands of hospitals, retail pharmacies, and some of the nation’s largest health systems to capture actionable intelligence, reduce risks and reinforce their commitment to delivering cost-effective, safety-centered, high quality medical care.

Quantros® Safety & Risk Management Solutions Suite

The Quantros Safety & Risk Management Solutions Suite enables healthcare providers to improve quality and patient safety by providing the information they need to prevent errors, improve outcomes, reduce risks and costs. Quantros offers a single access point for users to manage their safety-related claims, risk, event, and reporting activities. The applications support the reduction of patient safety events via automated alerts, real-time reporting and sophisticated root-case analysis. Organizations can use the application to correct an error-prone environment, reducing cost and the loss of internal resources.

 

 

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