Rates of Significant Preventable Adverse Events in Hospitalized Patients With Respiratory Disease

Patients admitted to the hospital with an acute illness secondary to respiratory disease are at increased risk of adverse events, many of which may be preventable. This study examined the incidence and nature of preventable adverse events (PAEs) leading to significant morbidity or mortality in a cohort of patients admitted with a primary respiratory presentation at an acute care hospital.

A review was conducted of patients admitted to a pulmonary ward at our center who were either transferred to the ICU or died on the ward between January 1, 2020 and April 19, 2021. Electronic medical records were reviewed for any indication of an event that led to clinical decompensation or death. Logistic regression was conducted to assess the association between select patient clinical factors and the occurrence of a PAE.

Out of 874 patients admitted to the hospital's pulmonary wards, 27 patients were transferred to the ICU because of worsening medical status, while another 55 patients died on the ward. Eight patients (30%) experienced a PAE consisting of either inadvertent oxygen removal (n = 4) or aspiration (n = 4) just before requiring transfer to the ICU. Thirteen of the deceased individuals (24%) experienced PAEs just before death, including inadvertent oxygen removals (n = 7), aspiration (n = 4), or oximetry malfunction (n = 2). No specific clinical factors that could be used to predict the occurrence of PAEs were identified.

Preventable adverse events were identified in over a quarter of admitted patients with respiratory disease who required an ICU transfer or died in-hospital. Enhanced surveillance of hospitalized patients with acute respiratory disease is warranted.