New report: gains in patient safety have stalled over the past decade

Hospital care helps patients recover from serious illness and injury but, all too often, patients can also be harmed by it.

In 2010, our office, the Office of Inspector General for the U.S. Department of Health and Human Services (HHS-OIG), reported that 27% of Medicare beneficiaries experienced harm during hospital stays. These harms were uncovered through an extensive medical record review by nurses and physicians trained in patient safety. They included temporary events such as low blood pressure that can cause falls and other problems, as well as serious events such as strokes and sepsis, which prolong hospital stays, cause permanent injuries, and, in some cases, contribute to death.

Almost half of the harm events identified could have been prevented by better care.

That study further galvanized the patient safety movement, which began a decade earlier when the Institute of Medicine’s report, “To Err is Human: Building a Safer Health System,” sent shock waves through the health care community. In the years since, providers, payers, patient advocates, and government have devoted unprecedented attention to making hospitals and health care safer. Yet a new study recently released by our office shows that rates of patient harm remain disturbingly high.

Based on hospital stays exactly 10 years later and using the same methodology as the 2010 report, our new study found that 25% of Medicare beneficiaries experienced harm during inpatient hospital stays, again almost half of which could have been prevented by better care.

This lack of substantial improvement is particularly disappointing, given the last decade’s technological revolution in health care, with advances in electronic health records and other innovations that offer such promise to improve patient care.

The greatest concern is the human toll caused by these events, resulting in the need for more care and sometimes life-sustaining interventions and long-term disability. But they also exact economic burdens on federal health care programs such as Medicare, the people who experience the harms, and the loved ones who care for them. These harms cost the Medicare program $520 million in extra spending on hospital care alone — in just one month.

The Covid-19 pandemic highlighted how much health care workers sacrifice to serve patients and their professional dedication to patient care. Yet the care they provide can also pose risks to patients, and federal policies to prevent harm do not address a broad range of common harm events. For example, our study found harm from surgical site infections, but the specific types of infections were not captured by payment incentive policies.

What patient harm occurs in hospitals and why?

Patient harm reflects a longstanding national crisis. Each individual story represents a hardship for the family involved, and sometimes a tragedy. Here are four examples:

• Providers delayed for five days a patient’s urgently needed surgery. A resulting cascade of events ended in the patient’s death.
• A 69-year-old hospitalized for hip replacement contracted methicillin-resistant Staphylococcus aureus (MRSA), an antibiotic-resistant superbug. This infection was preventable and caused a week-long hospital readmission and repeat hip surgery.
• A patient admitted with chronic diarrhea, fever, and sepsis was unable to move. Due to a failure of nursing care, the patient was not turned regularly in bed and developed pressure injuries in two different locations. Such injuries are often very painful and can lead to infection and tissue damage; some require surgical intervention.
• A patient experienced cardiac arrest while being transported within the hospital from the patient’s room to the medical imaging department. The emergency response team could not locate the patient to initiate timely resuscitation, and the patient died.

Many other events caused only temporary harm, such as low blood sugar or low blood pressure, but represent important care breakdowns that could have been worse had the harm not been identified and ameliorated, or had they occurred to frailer patients. Patient harm events related to medication accounted for 43% of all harm events. These events commonly involved patients who experienced excessive bleeding or delirium and other changes in mental status, often resulting from taking a combination of opioids.

Not all harm is preventable. Our work measured harm events resulting from all causes. Some cases involved medical errors and hospital systems failures, while others resulted from patients having multiple medical conditions that complicated care.

Updates to the methodology used in the two HHS-OIG reports and changes in the Medicare population over time — including increases in the prevalence of chronic illnesses and other medical conditions — preclude direct comparisons between the two studies. But the new findings did not show the type of improvement we had hoped for after a decade of sustained effort on improving patient safety.

Another key finding identified in both HHS-OIG reports was that the range of patient harm is much wider than lists of harm events included in federal policies and tracked by safety efforts would indicate. The earlier study identified many harms that were not captured by Medicare’s Deficit Reduction Act Hospital-Acquired Condition policy, which seeks to reduce patient harm by ensuring that payments do not cover harm events.

Although Medicare expanded this effort with its Hospital-Acquired Condition Reduction Program, the recent study found that narrow definitions of harm events still limit the effectiveness of these policies.

Medicare’s lists of conditions excluded most of the harm events that patients in our study experienced. Only 5% of the harms we identified were included on Medicare’s Hospital-Acquired Condition Reduction Program list, and only 2% were on the older Deficit Reduction Act Hospital-Acquired Condition list. Additionally, the Centers for Medicare & Medicaid Services (CMS) has suspended use of the Hospital-Acquired Condition Reduction Program policy during the Covid-19 pandemic.

What can be done to improve hospital care?

To prioritize safe, high-quality care, HHS and other payers must advance policies that incentivize better care. Recommendations in our new report include that CMS update and broaden the list of harm events included in payment incentive programs and expand the use of patient safety measures, and that the Agency for Healthcare Research and Quality (AHRQ) develop a model to disseminate information on national clinical practice guidelines and best practices to improve patient safety. Patients and families should also be involved, where possible, to engage in their own care, such as selecting providers based on quality measures, making informed choices about care providers and treatment regimens, and staying vigilant while undergoing hospitalizations and other medical care. The entire clinical team must work with patients and families to monitor each patient’s progress and speak up when problems arise.

After our 2010 report, AHRQ and CMS, both part of HHS, launched new initiatives to reduce harm, including an AHRQ system to identify harm through systematic review of medical records and additions to CMS’s list of hospital-acquired conditions which resulted in reducing certain types of events.

But they can do more. Our new report provides three recommendations for CMS and four for AHRQ that could further address these harm rates and promote patient safety in hospitals. As AHRQ and CMS move forward to implement our new recommendations, we will monitor their progress closely and will continue our work to uncover harm events and push for comprehensive and effective action at HHS.

Patient safety has been a focus of the medical community and policymakers for more than two decades. The new HHS-OIG report demonstrates that more work is needed and provides a reality check and a roadmap for further action. New and more effective methods must be developed by hospitals and their overseers. Reducing patient harm will require the ingenuity of American medicine and technology and marshalling resources, expertise, and innovation. It will also require accountability and conviction.

All involved must work with urgency to reduce the scale and persistence of patient harm in hospitals and throughout the health care system.

Christi A. Grimm is the inspector general of the U.S. Department of Health and Human Services. Ruth Ann Dorrill is a regional inspector general with the Office of Inspector General for the U.S. Department of Health and Human Services, where Julie K. Taitsman is the chief medical officer.