5 things to know about HHS OIG’s patient harm report

A quarter of Medicare patients experienced patient harm during their short-term acute-care hospital stays in 2018, and that rate barely changed from a decade earlier, according to a recent report.

The study, conducted by the Health and Human Services Department’s Office of the Inspector General, looked at a sample of 770 Medicare patients, out of approximately 1 million, who had inpatient stays during October 2018 at 629 hospitals nationwide.

Here are five highlights from the patient harm report:

1. Types of harm. While they don’t always involve negligence or poor care quality, patient harm events can often be caused by medical errors and general substandard care, the OIG found. Of the harm incidents studied, 43% were related to medication, 23% were related to patient care, 22% stemmed from procedures and surgeries and 11% were due to infections. Common types of medication-related harm events included acute kidney injuries, excessive bleeding, hypotension and delirium.

2. Adverse events. Of the 25% of Medicare patients who experienced harm, around half experienced adverse events, which led to longer hospital stays, permanent harm, life-saving intervention or death. The majority of adverse events, 74%, contributed to or resulted in a prolonged facility stay, care elevation, transfer to another facility or subsequent admission. Another 10% of adverse harm events contributed to patients’ death—an estimated 1.4% of the roughly one million hospitalized Medicare patients died during the month-long study period in 2018. Most of these patients had multiple complex comorbidities, including cancer, morbid obesity, dementia, kidney failure and diabetes.

3. Patient harm preventability. Physician reviewers selected by HHS determined that 43% of all adverse and temporary harm events were preventable in some way and 56% were not preventable. Among the preventable events, 33% involved patients receiving substandard treatment or therapeutic care and 31% involved patients receiving inadequate preventative care. In the OIG’s sample group, seven of the 11 adverse events that contributed to or resulted in death were preventable, reviewers determined.

4. Comparison to 2010 report. OIG first reported the national incidence rate of patient harm events in hospitals in 2010, based on a sample group of Medicare patients from October 2008. Patient harm rates have hardly changed since then, with 27% of patients experiencing harm events in 2008. Around 44% of these events were deemed preventable, similar to the latest report. The 2008 sample experienced slightly more adverse events and slightly less temporary harm events than the 2018 group.

5. Recommendations to avoid further incidents of patient harm. Based on its latest findings, the OIG said it is recommending that the Centers for Medicare and Medicaid Services broaden the number of hospital-acquired conditions listed under its harm-prevention incentive policies to include common, preventable, and high-cost harm events. Also, CMS should develop guidance for surveyors to assess hospital compliance with patient harm tracking and monitoring requirements, the OIG said. The watchdog recommended the Agency for Healthcare Research and Quality update its agency-specific Quality Strategic Plans and continue its efforts to develop new strategies to prevent common patient harm events in hospitals.