Hospital Patient Safety Report Provides Data, Analysis, and Recommendations
BALTIMORE (March 18, 2014) – The Department of Health and Mental Hygiene’s Office of Health Care Quality (OHCQ) has released its annual Hospital Patient Safety Report, which analyzes serious adverse events reported by Maryland hospitals in Fiscal Year 2013.
In Fiscal Year 2013, hospitals submitted 223 reports of Level 1 adverse events, down from 286 reports in FY 2012 and 348 reports in FY 2011. Level 1 adverse events are unexpected occurrences related to an individual's medical treatment and not related to the natural course of the patient's illness or underlying condition that results in death or a serious disability.
Key findings of the report include:
with over 301 beds reported an average of four events each in FY13, down
significantly from 6.4 events per hospital in FY12.
and pressure ulcers continue to make up the majority of the reports received,
with 73 and 52 reports, respectively. These accounted for nearly two-thirds of
all reports in FY13.
- Delays in treatment, after averaging 17 reports per year, increased significantly to 28 reports in FY13.
- Inpatient and outpatient attempted and completed suicides, after hitting a high of 16 in FY12, dropped to only 7 in FY13.
- Reports of airway misadventures, which previously averaged eight reports per year, increased to 12 in FY13. Two-thirds of these reports came from mid-sized hospitals of 201-300 beds.
- Three hospitals were cited for failing to satisfy the RCA requirements of COMAR 10.07.06.06. Commonalities among submitted poor quality root cause analyses include: A focus on what happened, rather than why; lack of identified causality and defined root causes; and ineffective interventions aimed at the bedside with no monitoring to determine the outcomes of the interventions.
These key findings have informed recommendations contained in the report. The recommendations include:
- Our largest hospitals should reevaluate their patient safety programs to ensure they are capturing and reporting all reportable adverse events.
- One way to decrease delays in treatment is to provide timely intervention, such as by supervisors who are actively engaged with assessing the well-being and the care being provided to all patients on the unit. Among other interventions, supervisors can activate the chain of command and facilitate timely assessments and definitive treatment.
- Hospital processes should be standardized as much as possible across similar care areas. For instance, the obstetrical operating suite should have the same policies for counting equipment as the general operating room.
- Hospitals should consider requesting that anesthesia providers evaluate the airways of patients with known or suspected difficult airways upon admission, rather than waiting and being unprepared for emergency interventions.
- Assessments and updates of skills such as dysrhythmia identification must occur periodically, not just at the time of hire.
- Hospitals must proactively address the contributing factors that are common in medication errors, including communication failures, lack of effective medication reconciliation, dosage calculation failures, and complacency.
- Root cause analysis teams must pay more attention to the role of staff supervision (or the lack thereof) in the adverse events. Many adverse events could be averted with timely interventions.
- Hospital leaders should participate in the root cause analysis process to gain valuable insight into the challenges faced by patients and by front line staff. Leadership participation also lets the staff know that administration supports the root cause analysis process. Most adverse events require some analysis of latent issues that hospital leadership is in a better position to rectify.
OHCQ works with Maryland hospitals and the Maryland Patient Safety Center to promote these and other recommendations.
To view the full Fiscal Year 2013 Hospital Patient Safety Report, visit http://dhmh.maryland.gov/ohcq/HOS/sitePages/Reports.aspx and click on the 2013 Report.
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