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According to a New Government Report
By Marian Wang
ProPublica, Nov: 16, 2010, 3:30 pm
One out of every seven hospitalized Medicare beneficiaries experiences an “adverse event,” which means the patient is harmed as a result of medical care. That’s according to a study released today [1] by the Department of Health and Human Services’ inspector general. The “adverse events” contribute to an estimated 15,000 patient deaths [2] each month and add at least $4.4 billion [3] to the government’s annual Medicare expenses, the report projected. These findings were based on a nationally representative random sample taken from the nearly 1 million Medicare beneficiaries discharged from hospitals in October 2008.
The report’s findings were “consistent with previous studies” but “nonetheless disturbing [4],” Carolyn Clancy, director of the Agency for Healthcare Research and Quality, said in a written response to the report.
Medicare and Medicaid chief Donald Berwick, in a separate response, said that his agency is working to improve care not only for hospitalized patients, but is also trying to address “issues in dialysis centers and ambulatory and long term care settings.”
Inspector General Report
It’s interesting that he mentions this. Because the inspector general report only covered hospital care, the statistics it contains don’t include many of the adverse events we’ve reported on in a particular subset of Medicare beneficiaries—patients receiving care in dialysis clinics [5].
Examples:
But, the report did highlight the story of one hospitalized dialysis patient who almost died when the tube feeding blood back into his body dislodged—an incident that as we’ve noted, is potentially deadly but also preventable [6]: [O]ne beneficiary had excessive bleeding after his kidney dialysis needle was inadvertently removed, which resulted in circulatory shock, a transfer to the intensive care unit, and emergency insertion of a tube into the trachea (windpipe) to ease breathing. When the tube was removed the following day, the patient aspirated (inhaled foreign material into his lungs), which required a life-sustaining intervention.
Assessment
Of the adverse events it identified, the inspector general’s report judged about 44 percent to be preventable. The inspector general called on both the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality to broaden the definition of adverse events and better measure such incidents, noting that “to date, no adverse event reporting system exists, and there are no Federal standards regarding State systems.”
Conclusion
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Filed under: Breaking News, Health Insurance, Quality Initiatives, Research & Development, Risk Management | Tagged: Agency for Healthcare Research and Quality, Carolyn Clancy, CMS, Department of Health and Human Services’, Donald Berwick, Marian Wang, ProPublica |
The Leading Business Education Network for Doctors, Financial Advisors and Health Industry Consultants 
Are Patients Any Safer-Today?
http://www.thehealthcareblog.com/the_health_care_blog/2010/11/could-it-be-that-patients-arent-any-safer.html#comments
Maybe; maybe not!
Karen
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ME-P UPDATE:
Did you know that a Senate investigation found that Medicare spent millions of dollars for stents implanted by a Maryland doctor accused of putting them in patients who didn’t need them, according to a report just released.
http://www.msnbc.msn.com/id/40534163/ns/health-health_care
The report released by the Senate Finance Committee said Dr. Mark Midei’s questionable implantations cost the Medicare program $3.8 million between 2007 and 2009. Sen. Max Baucus, D-Mont., the committee’s chairman, said the case could be a sign of a larger national trend of wasteful medical device use.
This is an ME-P follow-up on this previously reported incident.
Ann Miller RN MHA
[Executive-Director]
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Over-Diagnosis and Over-Treatment
[ … No Kidding]
In a new book, “Overdiagnosed: Making People Sick in the Pursuit of Health,” Dartmouth researchers and physicians argue that the medical establishment’s embrace of early diagnosis and treatment as the key to keeping people healthy actually does the opposite.
When doctors order screenings or tests for people who have no symptoms, then diagnose them with illnesses, that’s often overdiagnosis, these authors maintain. Since many of the patients will never develop symptoms, much less get sick or die from these ailments, it leads to costly, unnecessary medical interventions and promotes a culture of sickness rather than health.
Kent
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HHS Releases Quality-Improvement Strategy
HHS has unveiled its National Strategy for Quality Improvement in Health Care, a detailed road map the department says will guide future efforts to make care safer, more patient-centered and more affordable. Creation of the strategy was mandated by the healthcare reform law.
The national strategy establishes six priorities for improving care and population health, including making care safer by reducing harm; engaging patients and family members as partners; promoting preventive care; and working with communities to foster healthy living practices. HHS said it collaborated with clinicians, patients, payers, community agencies and other stakeholders to develop the strategy.
Source: Maureen McKinney, Modern Healthcare [3/21/11]
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More on Reducing Hospital Errors
http://online.wsj.com/article/SB10001424052748703859304576307060330715004.html
Tom
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On Medical Errors Outside the Hospital
Efforts to improve patient safety need to move beyond the hospital to outpatient settings such as doctors’ offices.
http://blogs.wsj.com/health/2011/06/14/time-to-focus-on-medical-errors-outside-the-hospital/
Karen
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