January 12, 2023 – Nearly one in 4 hospital patients will experience an opposed event during their hospital stay, with the likelihood of such events being lower in smaller hospitals than in larger ones, a brand new study shows.
The results were published today in New England Journal of Medicine.
The report is “disturbing” and a call to hospital management to prioritize patient safety, wrote Dr. Donald M. Berwick in a editorial The study is being supervised by Berwick, who's president emeritus and senior fellow on the Institute for Healthcare Improvement and former administrator of the Centers for Medicare & Medicaid Services.
He noted that “'First, do no harm' remains a sacred obligation for all in healthcare.”
Adverse events were defined as “unintentional physical injuries caused by or contributing to medical treatment that require additional monitoring, treatment, or hospitalization, or result in death.” Of the cases studied, there have been seven deaths, “one of which was considered preventable,” the researchers reported.
23% of the opposed events that occurred were preventable and 32% were classified as serious.
For the study, researchers analyzed a random sample of two,809 cases of individuals admitted to 11 Massachusetts hospitals in 2018. Registered nurses reviewed the records to discover opposed events using detailed criteria, including so-called “trigger” events that previous research has shown often result in opposed events. Doctors then reviewed the opposed event summaries compiled by the nurses.
The most typical events were:
- Drug incidents, defined as “injuries caused by ingested drugs” (39%)
- Surgical or other procedural events (30%)
- Care-related events comparable to falls and pressure ulcers (15%)
- Infections occurring within the context of healthcare (12%)
The researchers discovered patterns in who was most certainly to experience opposed events. Older patients were more prone to experience opposed events than younger patients. Male patients were more prone to experience opposed events than female patients.
Racial and ethnic differences were also observed. Patients of Asian descent were less prone to experience opposed events than black or white patients, and patients of Hispanic descent were less prone to experience opposed events than non-Hispanic patients.
“These numbers are disappointing but not shocking,” said study creator David Bates, MD, NBC News“They show that we still have a lot of work ahead of us.”
The authors stated that limitations of their study included the underrepresentation of patients who were primarily insured through Medicaid and that their approach likely missed some opposed events.
The 11 hospitals that provided data for the study were all insured by the identical skilled liability insurer, which, in keeping with the authors, provided “support” for the study as a part of the corporate’s mission.