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Nearly 1 in 4 US hospitalized patients experience harmful events, study finds

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Nearly 1 in 4 patients admitted to US hospitals will suffer harm, according to a study published Wednesday in the New England Journal of Medicine.

The stark findings underscore that despite decades of effort, US hospitals still have a long way to go in improving patient safety, experts say.

“These numbers are disappointing but not shocking,” said Dr. David Bates, chief of general medicine at Brigham and Women’s Hospital in Boston, who led the study. “They show that we still have a lot of work to do.”

The research analyzed the medical records of 2,809 patients who were hospitalized at 11 Boston-area hospitals in 2018. The study excluded people who were admitted for observation only or for palliative care, rehabilitation, addiction treatment, or psychiatric care.

Hospital data showed that 663 of the patients – around 24% – experienced at least one event during their hospital stay that negatively affected their health, even temporarily.

A total of 222 adverse events were considered preventable, meaning that errors resulted in harm to the patient. This translates to about 7% of the total hospitalizations analyzed by the researchers. Twenty-nine people, or 1% of the total number of people admitted, had serious preventable adverse events that resulted in serious harm. One death was considered preventable.

Most bad outcomes, however, were considered inevitable. They may include known side effects of certain medications or known risks associated with surgery.

The most common adverse events overall (nearly 40%) were related to medications administered in the hospital. Surgeries and other procedures accounted for just over 30%, followed by what the study authors called “patient care events” at 15%. They include falls and bed sores, both of which are considered preventable.

One bright spot, experts said, was that hospital-acquired infections accounted for only about 12% of adverse events — a significant decrease from a 1991 study that found infections to be the second most common adverse event.

The 1991 study, called the Harvard Medical Practice Study I, is considered landmark research. Using data from hospitalized patients in New York State in 1984, he found that only about 4% of hospitalized patients were harmed. However, the study looked for a smaller range of adverse events than the current survey, and hospitals have become much better at reporting harms when they occur.

“It’s clear that at least the rate is not going down and this damage remains a really serious problem,” Bates said.

The Doctor. Albert Wu, director of the Center for Health Services and Research Outcomes at the Johns Hopkins Bloomberg School of Public Health, said in an email that while progress has been made in some areas, new risks have emerged as medicine has advanced.

“Although we have eliminated some causes of harm, new types of harm have been created, associated with potent new drugs and new procedures,” said Wu, who was not involved in the new research.

For example, pharmaceutical companies have made significant strides over the three decades since the last report was published, but with an abundance of drugs available, more opportunities for medication-related errors arise.

“There are many more drugs available today compared to 1991, and some of the drugs have a lower therapeutic margin, which is the gap between the therapeutic effect and the dangerous dose,” said Dr. Donald Berwick, President Emeritus and Senior Fellow of the Institute for Healthcare Improvement in Boston. Berwick wrote an editorial that was published on Wednesday alongside the new study.

Even technologies implemented to prevent medication errors can create new opportunities for setbacks.

“New technologies are always a double-edged sword and intense vigilance is needed to monitor them. You need to anticipate what could go wrong and build dams around the hazards,” Berwick said.

Linda Aiken, professor and founding director of the Center for Health Outcomes and Policy Research at Penn Nursing in Philadelphia, said the heart of the patient safety issue is the staff.

“Since we’ve conducted patient safety research, we’ve consistently found that one of the main explanations for poor patient outcomes is insufficient nurses at the bedside,” she said. “Having a sufficient number of nurses is a foundation for safety.”

In a 2018 study published in the journal Health Affairs, Aiken and his team interviewed nurses in 535 hospitals across the US. Sixty percent reported that there were not enough nurses in their hospitals to provide safe care. The pandemic has already exasperated nursing staff, leading to strikes.

Only one state, California, has legal criteria on the minimum number of employees needed to keep hospitals safe. A nurse cannot care for more than five patients at a time.

“If you actually implemented a standard like this, it could save a lot of lives that fall under patient safety,” Aiken said. “These are preventable, but there are very few nurses there to provide the kind of care that would prevent these adverse events from happening.”

Experts said efforts must also be made to prevent damage that has been classified as unavoidable.

“Practices evolve so that unavoidable mistakes can be avoided by changes in practice,” Wu said. “For example, if you completely stop using a drug that [has a] high rate of unavoidable adverse effects, these adverse effects will no longer happen.”

Peter Pronovost, director of quality and clinical transformation at University Hospitals in Cleveland, used to work on preventing bloodstream infections, which were once considered “inevitable rather than preventable.”

“When we changed that narrative and used checklists, we reduced by 80% these infections that used to kill more people than breast or prostate cancer,” he wrote in an email.

Wu said patients should “keep in mind that there is potential for harm during hospitalization.” He encouraged patients to strive to be an active part of their healthcare teams, telling hospital staff what diagnoses they have, medications they are taking, allergies they have and care they have received elsewhere.

“If you think something might be wrong, speak up!” he said.

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