The Safety of Inpatient Health Care.

Area of Science:

• Healthcare Quality and Safety
• Medical Error Research
• Hospital Patient Harm

Background:

• The 1991 Harvard Medical Practice Study identified adverse events as a major source of patient harm.
• Significant advancements in patient safety have occurred since 1991, necessitating updated assessments.
• Current data on hospitalization-related harm is crucial for evaluating contemporary patient safety.

Purpose of the Study:

• To determine the frequency of patient harm during hospitalization.
• To assess the preventability and severity of adverse events in a recent cohort.
• To provide updated statistics on patient safety in Massachusetts hospitals.

Main Methods:

• Retrospective cohort study of admissions from 11 Massachusetts hospitals in 2018.
• Utilized a trigger method and medical record review to identify adverse events.
• Adjudication by physicians confirmed adverse events and their characteristics.

Main Results:

• Adverse events occurred in 23.6% of 2809 admissions.
• 22.7% of 978 identified adverse events were preventable.
• Serious or higher severity preventable adverse events occurred in 1.0% of admissions, with 7 deaths (1 preventable).
• Adverse drug events were most common (39.0%), followed by procedural (30.4%), patient-care (15.0%), and infection-related (11.9%) events.

Conclusions:

• Adverse events affect nearly one in four hospital admissions.
• Approximately 25% of adverse events were preventable, emphasizing the need for continuous improvement.
• Findings underscore the critical importance of ongoing patient safety initiatives.