1 in 20 Patients are Affected by Preventable Harm

July 17, 2019

Around 1 in 20 (6 percent) of patients are affected by preventable harm in medical care, of which around 12% causes permanent disability or death, finds a study published by BMJ.

Most preventable harm relates to drug incidents and invasive procedures and it is more common in surgical and intensive care units than in general hospitals.

Preventable harm also accounts for an estimated $9.3 billion (£7.3bn; €8.2bn) excess charges in the U.S. Similarly, the financial cost from only six selected types of preventable patient harms in English hospitals is equivalent to more than 2,000 salaried general practitioners or more than 3,500 hospital nurses each year.

As such, the researchers say strategies targeting preventable patient harm could lead to major improvements in medical care and considerable cost savings for healthcare systems across the globe.

Preventable patient harm is a serious problem across medical care settings globally, and early detection and prevention is an international policy priority. Several previous reviews have examined overall patient harm across different settings, but none have focused on preventable patient harm.

So a team of researchers led by Maria Panagioti from the NIHR Greater Manchester Patient Safety Translational Research Centre set out to measure the prevalence of preventable patient harm across a range of medical settings, including hospitals and in primary care. They also examined the severity and most common types of preventable patient harm.

Their findings are based on data from 70 observational studies involving 337,025 mostly adult patients. Of these, 28,150 experienced harmful incidents and 15,419 experienced preventable harmful incidents.

Around 12% of the preventable harm was severe (causing prolonged, permanent disability or death), while incidents relating to drugs and other treatments accounted for almost half (49%) of preventable harm

Compared with general hospitals, preventable harm was more common in patients treated in surgical and intensive care units, and was lowest in obstetric units.

Despite the unique focus on preventable patient harm and several method strengths, this review has some limitations, say the authors. For example, variations in study design and quality of documentation used for detecting preventable patient harm may have led to differences in prevalence estimates.

Nevertheless, they say their findings "affirm that preventable patient harm is a serious problem across medical care settings" and "priority areas are the mitigation of major sources of preventable patient harm (such as drug incidents) and greater focus on advanced medical specialties."

It is equally imperative to build evidence across specialties such as primary care and psychiatry, vulnerable patient groups, and developing countries, they add. "Improving the assessment and reporting standards of preventability in future studies is critical for reducing patient harm in medical care settings," they conclude.

This view is supported by experts at the London School of Economics and Harvard Medical School in an editorial. They say this study "serves as a reminder of the extent to which medical harm is prevalent across health systems, and, importantly, draws attention to how much is potentially preventable."

Moving forward, they say "efforts need to be focused on improving the ability to measure preventable harm. This includes fostering a culture that allows for more systematic capturing of near misses, identifying harm across multiple care settings and countries, and empowering patients to help ensure a safe and effective health system."

Source: BMJ


Report From The Leapfrog Group Examines Hospital Policies on Never-Events

June 27, 2019

The Leapfrog Group, a national watchdog organization of employers and other purchasers focused on healthcare safety and quality, today released its 2019 Never Events Report, and found that one in four participating hospitals do not meet The Leapfrog Group's standard for handling of serious reportable events that should never happen to a patient, known as "Never Events." The report is based on the findings from the 2018 Leapfrog Hospital Survey, with data voluntarily submitted by more than 2,000 U.S. hospitals.

The report calls attention to official hospital policies for responding to the 29 serious reportable events as identified by the National Quality Forum (NQF). These include errors and accidents that hospitals should always prevent, such as surgery on the wrong body part, foreign objects left in the body after surgery, death from a medication error, and others that stakeholder consensus has defined as always preventable. The Leapfrog standard for hospital policies includes such steps as: an apology to the patient, not charging for the event, a root cause analysis that includes interviews with patients and family, reporting to appropriate officials, implementing a protocol to care for the caregivers involved and making the policy available to patients and payors.

"When a terrible error occurs, Leapfrog and its constituency of employers and other purchasers expect hospitals to respond with the highest levels of respect and compassion for patients and their families, beginning with a simple apology. Then, hospitals should rely on the sound business principles that all other industries routinely apply when a serious and harmful error occurs, like not charging for the problem and doing a root cause analysis to prevent future reoccurrences. That's what the Leapfrog Never Events Policy is all about," said Leah Binder, president and CEO of The Leapfrog Group. "Patients and payors alike expect that 100 oercent of hospitals will adhere to these basic principles, but unfortunately, we are not seeing that yet, with only 75 percent of reporting hospitals meeting Leapfrog's standard."

Leapfrog's Never Events Policy includes nine basic principles for response if a Never Event does occur, which is expanded from five principles first issued in 2007. In 2017, The Leapfrog Group's expert panel recommended adding four new principles as a result of new evidence and testing of best practices by leading health systems, as well as work by national organizations including the Agency for Healthcare Research and Quality and the National Patient Safety Foundation.

The report also found a distinction between how rural and urban hospitals adopt the Never Events Policy. More hospitals in urban areas (77 percent) are meeting Leapfrog's new standard compared to hospitals in rural areas (64 percent).

Consumers and purchasers can and should use Leapfrog's publicly reported Survey results, available for free at, to determine which hospitals in their community have a Never Events Policy that fully meets Leapfrog's standard, and which hospitals declined to disclose the information.

Source: The Leapfrog Group

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