The Buzz This Week

March 12 to 18 marks the annual Patient Safety Awareness Week, which was created by the Institute of Healthcare Improvement (IHI) following the National Academy of Medicine’s seminal 1999 report, To Err Is Human, which estimated that as many as 100,000 Americans die annually due to medical errors that could have been prevented. More recent studies suggest as many as 400,000 deaths occur in the U.S. each year as a result of medical errors or preventable harm.

Related to Patient Safety Awareness Week, Healthgrades awarded its Patient Safety Excellence Award to 445 hospitals that fell into the top 10% of hospitals based on 14 indicators. Those hospitals’ patients were, on average, 50% to 70% less likely to experience certain adverse events, including in-hospital falls resulting in hip fracture, collapsed lungs due to chest procedures, in-hospital pressure sores or bed sores, and catheter-related blood stream infections. Also released this week, Emergency Care Research Institute’s annual report on top patient safety concerns identified pediatric mental health, addressed in a previous Top Reads, as the No. 1 safety concern health system leaders will need to address in 2023, followed by violence against healthcare staff, uncertainty with maternal-fetal medicine, and multiple concerns surrounding medication safety and treatment timelines.

Despite more than 2 decades of awareness and efforts to improve patient safety, a 2022 study from the Office of the Inspector General (OIG), revealed that 25% of Medicare beneficiaries experienced preventable harm during inpatient stays in 2018—only a slight improvement from the 27% found to have experienced preventable harm10 years prior, in 2008. Another recently published study by Mass General Brigham found that almost 25% of all inpatients in their Massachusetts study cohort (not just Medicare patients) experienced an adverse event during a hospital stay in 2018, and of those events, 32% “caused harm that resulted in substantial intervention or prolonged recovery." 

A larger study with nearly 250,000 inpatients across the U.S., published by the Journal of the American Medical Association last year, found more encouraging results, citing significant decreases in adverse events between 2010-2019 for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures. There was a smaller reduction in adverse events for the “all other conditions” category, which the study authors noted could potentially be due to more targeted quality improvement and patient safety efforts for the aforementioned 4 conditions, not paired with similar efforts broadly applied to other areas.

More recent data that includes the years in which COVID-19 has been present are limited, given typical research and publishing timeframes. However, a study conducted by The Washington Department of Health found that preventable serious adverse events increased 61% between 2019 and 2022, serious patient pressure ulcers acquired after admission increased more than 95%, and patient falls resulting in death or serious injury increased more than 40%—demonstrating  the problem is getting worse, at least in some areas.

Despite these mixed results showing some evidence of improvement but also a worsening of certain conditions, improving patient safety continues to be a high priority for healthcare organizations, regulators, and patients and families. In the American College of Healthcare Executives’ (ACHE’s) latest hospital CEO survey, patient safety and quality was ranked fourth out of 11 as a top concern and pressing issue, behind (1) workforce challenges, (2) financial challenges, and (3) behavioral health/addiction issues.

Why It Matters

Medical advances such as vaccines, blood transfusions, new medicines, and gene therapy are just some examples of innovations that have extended the lifespan of people over the last few decades. However, with all novel advances, new risks can be introduced as well. These can include harm associated with new medications or medication interactions, new procedures, inadequate training in applying these advances or in new processes associated with them. In the worst cases, adverse events can lead to longer hospital stays, permanent harm, the need for life-saving intervention, or death.

Research shows that staffing is part of the patient safety issue. Linda Aiken, Professor and Founding Director of the Center for Health Outcomes and Policy Research at Penn Nursing in Philadelphia, commented “…since we’ve been doing research on patient safety, we consistently find that one of the major explanations for poor patient outcomes is insufficient numbers of nurses at the bedside,” a problem that presumably has been exacerbated by the pandemic. A 2018 study led by Aiken found that 60% of nurses reported there weren't enough nurses at their hospital to provide care—and that was pre-pandemic. The staff to patient ratios have only become worse in the last 3 years. Decades of data shows that higher nurse staffing levels are directly associated with lower patient mortality and failure to rescue rates, fewer adverse patient events, and shorter lengths of stay.

Adverse events that lead to additional necessary treatment inevitably translate into higher-cost care. These costs can come as unanticipated expense for the patients, higher costs for a patient’s insurance plan, and costs to the hospital in the form of additional resources and staff. The OIG’s research estimated that, in 2018, adverse events cost the Medicare program $520 million in extra spending on hospital care in just 1 month.

Efforts are being made across the healthcare industry to address patient safety issues. The Joint Commission elevated health equity to a National Patient Safety Goal, effective July 1, 2023. Medical schools have attempted to integrate patient safety initiatives into their program curriculum to educate students earlier in their careers. The Washington State House of Representatives is currently reviewing several bills recently introduced to help rectify the nursing crisis and improve patient safety. Artificial intelligence is being leveraged in many ways to provide greater efficiency in diagnosis and to support clinical decision-making, with the goals of reducing adverse events and leading to better outcomes. Several innovative approaches are being used to allocate administrative tasks away from nurses to free up their time for direct patient care. For example, LifeBridge Health introduced iPads to connect inpatients with nurses in Israel for “non-touch” tasks, freeing up bedside nurses for more complex, hands-on on tasks. Cedars-Sinai Medical Center has implemented “Moxi” robots to conduct simple but time-consuming tasks, like delivering lab samples and collecting medicine from the pharmacy, to free up nurses’ time for patient care and improve workflows.

Medical advances and the growth and evolution of provider health systems is leading to a remarkable age in healthcare, but they also bring an increasing complexity in the care itself and technologies being used, which can contribute to human error and adverse events. To make meaningful improvements and see lasting change, it is essential to make patient safety an organizational priority, committing to invest in change, and engage in targeted initiatives. In a recent interview, Andrew Resnick, MD, Chief Medical and Quality Officer at Chartis, reminds organizations “to start on the journey, knowing it’s not solved in a few days, but also cannot wait.”


The Joint Commission: The Joint Commission Elevates Health Care Equity Standard to National Patient Safety Goal 

Modern Healthcare: Pediatric Mental Health a Top Patient Safety Concern of 2023: ECRI 

NBC News: Nearly 1 in 4 U.S. Hospitalized Patients Experience Harmful Events, Study Finds

Health Affairs: Nurses’ and Patients’ Appraisals Show Patient Safety in Hospitals Remains a Concern

Editorial advisor: Roger Ray, MD, Chief Physician Executive.


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