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Government Report Finds Alarming Number of Preventable “Adverse Events” Affect Medicare Hospital Patients
The U.S. Department of Health and Human Services has issued a report that finds that 1 in 7 Medicare patients suffered an “adverse event” while hospitalized.
THE KEY FINDINGS INCLUDED THE FOLLOWING:
- An estimated 13.5 percent of hospitalized Medicare beneficiaries experienced adverse events during their hospital stays.
- This rate projects to an estimated 134,000 Medicare beneficiaries experiencing at least 1 adverse event in hospitals during the 1-month study period.
- An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.
- An additional 13.5 percent of Medicare beneficiaries experienced events during their hospital stays that resulted in temporary harm.
Temporary harm events are those that require intervention but do not cause lasting harm. Although many cases represent fairly minor occurrences, such as hypoglycemia, others were classified as temporary harm only because the patients were in the hospital for lengthy periods as a result of other, more serious, diagnoses, allowing hospitals enough time to address the harm prior to discharge. Additionally, 28 percent of beneficiaries who experienced adverse events also had temporary harm events during the same stay.
Signficantly, physician reviewers determined that 44 percent of adverse and temporary harm events were clearly or likely preventable.
Preventable events were linked most commonly to medical errors, substandard care, and lack of patient monitoring and assessment. Physician reviewers assessed events as not preventable when they occurred despite proper assessment and care or when the patients were highly susceptible to the events due to health status. Nearly all events on the NQF and Medicare lists were assessed as preventable, a key criterion of both lists.
Hospital care associated with adverse and temporary harm events cost Medicare an estimated $324 million in October 2008. Sixteen percent of sample beneficiaries in the Medicare Inpatient Prospective Payment System who experienced events incurred additional Medicare costs as a result. The added costs equate to an estimated 3.5 percent of Medicare’s expenditure for inpatient car 3.5 percent of the $137 billion Medicare inpatient expenditure for FY 2009 equates to $4.4 billion spent on care associated with events. Two-thirds of Medicare costs associated with events were the result of entire additional hospital stays necessitated by harm from the events. Additionally, these Medicare cost estimates do not include additional costs required for follow-up care after the sample hospitalizations.
See full report