That’s not news to pathologists, who often see how physicians mis-order or mis-interpret clinical laboratory tests
Each month, one out of seven Medicare patients is injured or killed by their healthcare providers. These medical errors cost taxpayers hundreds of millions of dollars each year. And, that doesn’t even include the cost of follow-up care for the injured patients who survive.
Those and other conclusions are part of a recently released study by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) titled “Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.”
Of course, these findings will not surprise pathologists and clinical laboratory managers. Each day, they recognize how certain physicians consistently order the wrong tests for their patients. Similarly, pathologists and medical laboratory scientists regularly get requests for consultations by these same physicians, who need help to properly interpret the medical laboratory test results and select an appropriate therapy for their patients.
(Deaths due to medical errors in 1997 compared to other leading causes of death. Sourced from Commonwealth publication #830.)
Shocking Results in the Quality of Care Delivered to Medicare Patients
The OIG looked at a random national sample of 780 Medicare patients who were discharged during October 2008. The OIG employed qualified physicians who reviewed the discharge data and determined:
- “whether an adverse event occurred,
- “whether the event was on the National Quality Forum (NQF) list of Serious Reportable Events or the Medicare list of hospital-acquired conditions (HAC),
- “what the level of harm was to the patient, and,
- “whether the event was preventable.”
To define what constitutes an adverse event, the OIG drew from the NQF and HAC lists, along with events from a patient harm index, to create an estimated adverse event incidence rate in four categories:
- prolonged hospital stays,
- permanent harm,
- life-sustaining intervention, or
- death.
The results of the study are shocking. According to the OIG report, 13.5% of all Medicare patients experience adverse events during hospital stays. That translates to 134,000 Medicare patients in a single month who will experience adverse events during hospital stays.
The OIG further broke out the data into sub-categories:
- 0.6% of beneficiaries had an NQF Serious Reportable Event,
- 1% had a Medicare HAC event,
- 13.1% experienced an adverse event resulting in the four most serious categories of patient harm, and sadly,
- an estimated 1.5% of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.
That bears repeating—15,000 Medicare patients experienced an adverse event while hospitalized that contributed to their deaths—in one month.
The physician reviewers further determined that 44% of all the events were preventable, and “were linked most commonly to medical errors, substandard care, and lack of patient monitoring and assessment.”
“This report suggests you’d have to be a daredevil to allow yourself to be admitted to a hospital,” said The Leapfrog Group’s CEO, Leah Binder, in a Modern Healthcare article. “What other industry in human history has a rate of injury like that? Maybe tightrope walkers or people who get shot out of cannons.”
The Cost of Medical Errors to the Medicare Program
The OIG calculated that the additional expenditure as a result of the medical errors for the month of October 2008 alone was $324 million, due to additional hospital stays required for patients to recover from the adverse harm they received. That equates to 3.5% of Medicare’s total expenditures, or $4.4 billion in 2009 taxpayer dollars.
These more recent findings by the OIG affirm the conclusions published in 1999 by the Institute of Medicine (IOM) in its report titled “To Err is Human: Building a Safer Health System.” This study estimated that as many as 98,000 people died each year due to preventable medication and surgical errors. This far exceeded the number of deaths each year due to auto accidents, breast cancer, and AIDS.
Though the new OIG report looks specifically a Medicare beneficiaries, it’s clear much more needs to be done to reduce preventable medical errors nationwide, and to curtail the sky rocketing cost of healthcare. Clinical laboratory managers and pathologists will understand that any policy directed at hospitals to accomplish this goal by default affects the way clinical laboratories support clinical services within their parent hospitals and health systems.
—Michael McBride
Related Information:
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries
To Err Is Human: Building a Safer Health System
Crossing the Quality Chasm: A New Health System for the 21st Century
