Thursday, November 25, 2010

Preventable Harm in Hospitalized Patients

Following on from my recent discussion about the use of trigger tools, a paper just published in the New England Journal reports the rate of preventable harm occurring in patients admitted to 10 North Carolina hospitals over a 6 year period. The authors used a validated trigger tool to analyze charts from 100 admissions per quarter.
The results are very alarming; despite a reputation as being a state that is very proactice in efforts to reduce harm, there was no reduction in harm over the study period. For every 100 admissions, there were 25 episodes of harm. It is important to point out that not every one of these episodes caused serious harm. 18% of patients were harmed as a result of medical care. 63% of these episodes were considered to be preventable. Of the harm episodes considered to be preventable, 26% caused permanent damage, were life threatening or caused or contributed to a patient death. overall 2.4% of harms caused or contributed to a patients death.
The most common errors arose from procedure complications, hospital acquired infections and medication errors.
This paper is a wake up call for the patient safety movement; despite much apparent and real progress over the past decade, it is a cause for concern that there has been no significant improvement in patient safety. There are likely many reasons for this; patient safety has not been a research priority, safety always involves a cultural shift within in heathcare which can be very difficult to achieve, and by not involving the younger generation of healthcare professionals, especially at their training stage, we are adding to the difficulty.

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