Despite patient safety efforts, adverse events in hospitals still common, study shows

Researchers and advocates have been calling attention to preventable patient safety issues—such as medication errors, falls, wrong limb amputations, and other medical errors—for decades. Since 2000, advances in medical care such as improved hand-washing, safe surgery checklists, safety guidelines to reduce infection risk, EHR alerts, “Never Event” designations, and many other changes have significantly reduced the rates of certain patient safety events.

“Despite stunning advances in medical science, we still have important gaps in patient safety.”

David W. Bates et al., The Safety of Inpatient Care, New England Journal of Medicine

Despite these improvements in care, a recent study in the New England Journal of Medicine finds that adverse events are still incredibly common for hospitalized patients. Within a random sample of 2,809 hospital admissions from 11 Massachusetts hospitals in 2018, nearly one quarter (24%) of admissions had one or more adverse event that caused at least temporary harm to patients, and about 8% of admissions had one or more adverse event that was serious, life-threatening, or fatal.

How much of this harm was preventable? In the NEJM study, about 7% of admissions had at least one preventable adverse event and 1% had a preventable adverse event that was serious, life-threatening, or fatal. These results are similar to those from a 2019 systematic review of preventable harm in The BMJ that found a 6% rate of preventable patient harm and 0.07% rate of severe preventable harm in medical settings. 

At least one adverse event was found in 24% of hospital admissions — that’s almost a quarter of admissions

David W. Bates et al., The Safety of Inpatient Care, New England Journal of Medicine

How much better are we doing on patient safety now compared to twenty years ago? In 2000, the rate of adverse events leading to prolonged hospitalization, disability, or death was estimated at a range of 2.9-3.7%. That’s much less than the 8% rate of serious adverse events found in the NEJM study. However, the NEJM study authors note that it’s difficult to make exact comparisons across years for a few reasons: 1) electronic health records have made it easier to find adverse events when they occur, 2) definitions of adverse events and the types of events we count have changed, and 3) the hospital patient population as a whole is sicker than it used to be, as a lot of care has shifted to outpatient settings.

Medication nation

Another reason behind the prevalence of adverse events could be the increasing use of multiple medications among older adults. As polypharmacy (use of many medications) has increased, harm from polypharmacy—what experts call “Medication Overload” has also increased. In a 2019 report, the Lown Institute estimated that in 2018, 5 million older Americans—one in ten—sought medical attention as a result of a serious reaction to medication. The report also finds that from 2005-2014, the rate of emergency room visits for adverse drug events among older Americans nearly doubled.

Unfortunately, this latest study shows that adverse drug events are still a large source of harm in the hospital. Among the 978 adverse events tracked in the NEJM study, 381 (39%) were adverse drug events—a higher rate than surgery-related events (30%), patient care events (15%), or healthcare-associated infections (12%).

About 27% of these adverse drug events were characterized as preventable, so there is a lot of room for improvement. In the Lown Institute’s Medication Overload Action Plan, there are numerous recommendations for reducing adverse drugs events in the hospital, such as: Conducting prescription checkups to identify potential drugs to deprescribe, adding pharmacists to hospital care teams, and disseminating deprescribing guidelines to hospital clinicians.

The need for system change

Although quality improvement programs have made a difference in reducing certain patient safety events, patient safety experts stress that tackling each patient safety issue one at a time isn’t enough —we need to create a culture of patient safety in our hospitals. That means emphasizing teamwork, continuous learning, safe staffing, and open communication about errors. Rather than react to patient safety issues individually, hospitals should have a process for continuous measurement and improvement.

“The next challenge in patient safety is enabling organizations to measure and reduce harm both inside and outside the hospital, continuously and routinely.” 

David W. Bates and Hardeep Singh, “Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety,” Health Affairs, 2018

Shifting from individual metric improvement to systems change is easier said than done. Especially coming out of the Covid-19 pandemic, many hospitals are struggling to stay solvent and staffed, let alone implement broad changes. While hospitals can be penalized for poor performance on patient safety, this may not be enough to overcome the financial incentive to keep hospitals understaffed.

As patient safety experts Dr. Gordon Schiff and Dr. Kaveh Shojania wrote in The BMJ last year, “We have done little to reduce the production pressures that drive care at the frontlines, nor improve nurse staffing ratios, support expanded use of clinical pharmacists, or apply design thinking and human factors engineering in robust ways.” Encouraging hospitals to adopt a culture of patient safety is not enough when so many other incentives push hospitals to prioritize profits over patients.

Hospitals leading the way on patient safety

However, some hospitals are proving that excellent patient safety is achievable. The following hospitals are ranked highest for patient safety on the Lown Institute Hospitals Index for 2022.

Patient Safety measures how well hospitals avoid preventable patient safety errors, using well established indicators provided by CMS on its Hospital Compare website for hospitalizations—such as rates of pressure ulcers, accidental punctures, and central intravenous line infections—for hospital admissions in 2018. The metric includes the CMS composite measure (PSI-90), which comprises 10 separate indicators of patient safety, as well as five hospital acquired infection measures.

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