A quarter of Medicare patients treated in acute care hospitals prior to the pandemic experienced patient harm, 43% of which was likely preventable, according to a new study from a federal watchdog.
Alongside the worsened outcomes, almost a quarter of patients who experienced harm required additional treatments estimated to drive “hundreds of millions of dollars” in additional Medicare costs as well as potentially patient costs, the Department of Health and Human Services' (HHS') Office of Inspector General (OIG) wrote.
"Although HHS agencies have reported progress during the past decade toward improving patient safety, protecting the health and safety of beneficiaries remains one of HHS' top management and performance challenges,” the inspector general wrote in the report. “An increased understanding of the prevalence and nature of patient harm will further assist efforts to reduce patient harm events and the factors contributing to these events.”
To conduct its investigation, OIG reviewed a random sample of 770 Medicare patients discharged from acute care hospitals during the month of October 2018. These records were screened by nurses and, if flagged, subsequently reviewed by physicians who determined whether a patient harm event occurred, its severity, whether it was preventable and why it occurred.
Among the 25% of patients who experienced harm, 13% were deemed temporary harm events and 13% were adverse events “that led to longer hospital stays, permanent harm, life-saving intervention or death,” OIG wrote in the report.
Patient harm events were most often (43%) tied to medications, followed by patient care (23%), procedures and surgeries (22%) and infections (11%).
Among the 43% of harm events deemed preventable, physician-reviewers most often attributed the event to “substandard or inadequate care” provided to patients by caregivers. If these preventable events were excluded, OIG’s analysis would have found an overall harm rate of 13% rather than 25%, the office wrote.
The study suggests a minor improvement over the 27% harm rate observed in a 2010 OIG analysis of Medicare patients hospitalized in October 2008. However, OIG wrote that the “scale and persistence” of these events over that decade requires HHS leadership and its agencies to “work with urgency” to cut down patient harm.
OIG’s analysis led to seven recommendations for the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ), such as the development of interpretive guidance for surveyors on hospital compliance with patient harm tracking requirements. CMS and AHRQ concurred with each recommendation, OIG wrote.
“OIG appreciates the efforts of CMS, AHRQ, and other HHS agencies to improve patient safety and promote quality of care,” the inspector general wrote in the report.
While OIG’s study focused on patient safety prior to the pandemic, quality watchdog groups have raised flags about potentially worsening conditions and experiences as hospital workforces contend with COVID-19 stressors.
Just this week, the Leapfrog Group released its latest batch of hospital patient safety ratings and a concurrent patient experience report that suggested general declines among “several” measures concurrent with the onset of the COVID-19 pandemic.