Adverse Events in Hospitals
Ruth Ann Dorrill, a Deputy Regional Inspector General for the Office of Evaluation and Inspections in Dallas, is interviewed by Roberta Baskin, OIG Director of Media Communications.
[Roberta Baskin] I'm Roberta Baskin, Director of Media Communications, speaking with Ruth Ann Dorrill, Deputy Regional Inspector General for our Office of Evaluation and Inspections, about a major series of reports on adverse events in hospitals. Ruth Ann, this is such an important topic, affecting families across America. So just tell us how you got started.
[Ruth Ann Dorrill] Well, we began this work in response to a mandate from Congress which directed the Inspector General to determine how often Medicare patients are harmed as the result of medical care--what we call "adverse events"--and the cost of these problems to the Medicare program. Examples of an adverse event is an infection, a surgical complication, a medication error, something negative that happens as a result of their care. We focused on hospitals because hospital care is the largest portion of Medicare costs, with 12 million Medicare patients hospitalized each year. Our studies describe how frequently adverse events occur, the severity of the harm, whether hospitals knew about the events when they happened , and what hospitals and Government did to address the problems. Unfortunately, we found that harmful events occur quite often.
[Roberta Baskin] These hospital evaluations take significant time and work. So how'd you go about it and what else did you find?
[Ruth Ann Dorrill] Well, we arranged for some of the nation's top physician experts to examine hospital medical records. And they found that 1 in 7 hospitalized Medicare patients experienced an adverse event that was serious enough to prolong hospitalization, cause permanent bodily harm, require life-sustaining intervention, or resulted in their death. And so, on a national scale, this means that in just a single month, an estimated 134,000 hospitalized Medicare patients experienced serious problems. And 15,000 of those died as a result of the medical harm.
[Roberta Baskin] What about less serious adverse events in hospitals?
[Ruth Ann Dorrill] Less serious harm also occurred, such as allergic reactions and injuries from falls. And many patients experienced multiple events, including one elderly heart patient who had six separate harmful events during a single hospital stay. Overall, a quarter of Medicare patients experienced harm and it cost the Medicare program and estimated 4.4 billion dollars.
[Roberta Baskin] 4.4 billion... well, plus the impact on patients' lives. Were these harmful events caused by medical errors?
[Ruth Ann Dorrill] Some were caused by errors, but not all. The physicians found that hospitals could have prevented 44 percent of the harmful events. So, almost half. Sometimes, hospitals can't avoid it, particularly when patients are frail or have complicated health problems. But hospitals can avoid enough medical harm to make a very strong case for improved practices.
[Roberta Baskin] What are hospitals doing to improve care?
[Ruth Ann Dorrill] Quite a lot. Many hospitals are taking big steps to reduce patient harm. And, this includes changing hospital systems to reduce the odds of human error and adopting practices that are known to provide better care with less risk of harm. And in many of the cases we found, hospital staff acted very quickly to address problems to avoid more serious harm. But, many of the hospitals don't know when harm occurs within their walls. We found in another study that hospital staff reported only 14 percent of the events that happened, most often because the staff didn't recognize what was happening as harm. Hospitals only changed their policies as the result of a handful of these events.
[Roberta Baskin] What action has Government taken to improve practices and reduce harm?
[Ruth Ann Dorrill] Well, this is definitely a shared responsibility between the hospital industry and the Government. And, the short answer is that we've made progress, but we need continued focus and meaningful action. The Federal Government and the States, for example, require that hospitals maintain patient safety standards, but we found that these standards are not universally enforced. For example, one of our studies found that after a harmful event occurred, hospital inspectors didn't always ensure that the hospital fixed the problem or that they had systems in place to identify and correct future problems. The Government is becoming more attuned to patient safety and more active in finding solutions though. For example, in 2011, the Centers for Medicare & Medicaid Services launched the Partnership for Patients, which is a project aimed at improving the health care quality and safety. And the Agency for Healthcare Research and Quality recently established a network of Patient Safety Organizations. The organizations will receive reports from hospitals when harm occurs and analyze what happened and recommend solutions.
And, there's a steep learning curve. It is important to appreciate that this is very complex work and an ever-changing target. And, as medical science progresses, the task of ensuring patient safety escalates as well.
[Roberta Baskin] Well, give us a brief look ahead... does the Inspector General plan more work in this area?
[Ruth Ann Dorrill] Yes, we're beginning a study that will look at these same issues in nursing homes: how often harm occurs; whether it is preventable by nursing home staff; and what the cost is to Medicare.
[Roberta Baskin] Ruth Ann, thank you for sharing this important work on hospital safety.
[Ruth Ann Dorrill] Thank you, Roberta.