Between 2006 and 2008, more than 958,000 medical safety events occurred involving Medicare beneficiaries, resulting in nearly $8.9 billion in excess costs. If facilities focused on better performance measures, an estimated 218,572 of these events, accounting for $2.1 billion in excess costs, could potentially be avoided, according to the seventh annual HealthGrades study on patient safety.

“Patient safety events are not only common, but costly,” the report stated. Overall, the total number of patient safety events affected 908,401 Medicare beneficiaries and represented 2.29 percent of all hospitalizations.

During the study, HealthGrades evaluated charts from 39.5 million hospitalizations at 5,000 non-federal hospitals across the country for trends in 15 patient safety indicators such as decubitus ulcer, iatrogenic pneumothorax, deep vein thrombosis and others designated by the Agency for Healthcare Research and Quality (AHRQ).

According to the report, of the Medicare beneficiaries who experienced one or more of the 15 patient safety indicators, 99,190 deaths occurred. One in 10 of these patients who exhibited the signs of at least one safety indicator died as a result, the report noted.

Additional data referenced from Zhan et al showed that 97.19 percent of these deaths of Medicare patients were directly correlated to at least one of the safety events.

Four safety indicators which caused the highest rates of medical errors were: failure to rescue, decubitus ulcer, post-operative respiratory failure and post-operative sepsis. The rates--measured by event rates per 1,000 patients--were recorded as 92.71, 36.05, 17.52 and 16.53 percent, respectively. 

Moreover, these four safety indicators accounted for 61.96 percent of all of the patient safety events recorded.

While incidence rates for failure to rescue improved by almost 7 percent between 2006 and 2008, rates of incidence for decubitus ulcer, post-operative respiratory failure and post-operative sepsis plummeted by 35.91, 6.2 and 25.96 percent, respectively.

Six indicators—complications of anesthesia, failure to rescue, selected infections due to medical care, post-operative hemorrhage or hematoma, post-operative abdominal wound dehiscence and accidental puncture or laceration—improved between 2006 and 2008.

However, while these indicators showed modest improvement--on average 10.66 percent--these indicators account for only 20.16 percent of all of the overall safety events that occurred to Medicare patients.

On the other hand, rates of eight indicators that accounted for almost 80 percent of the overall patient incidences— bed sores, iatrogenic pneumothroax, post-operative hip fracture, postoperative physiologic and metabolic derangements, post-operative respiratory failure, post-operative pulmonary embolism or deep vein thrombosis, post-operative sepsis or transfusion—worsened.

According to the study, decubitus ulcer and post-operative respiratory failure, the two most common indicators, accounted for 50.72 percent of the $8.9 billion in excess costs.

“While many suggest that the increased rates of patient safety indicators are attributable to an increase in detection and/or reporting, these causes should not be used as stand-alone explanations,” the report said.

The government is striving to create efforts to eliminate “never events (patient safety events that should never happen)” and holding providers accountable for avoidable medical errors,” like those mentioned above, according to HealthGrades.

Researchers also assessed 12 of the 15 patient safety indicators at facilities to evaluate performance and help identify the “best-performing hospitals” to establish a best-practice benchmark against which other hospitals could be evaluated.

The set of hospitals included 740 teaching hospitals and 848 non-teaching hospitals. HealthGrades then recognized the top 15 percent (238 hospitals) with the 2010 Patient Safety Excellence Awards. According to the study, the top-rated hospitals represented less than 5 percent of all U.S. hospitals in the study.

“We found that there were wide, highly significant gaps in individual patient safety indicators and overall performance between the hospitals recognized with the HealthGrades 2010 Patient Safety Excellence Award and the bottom-ranked hospitals,” the report stated.

Additionally, the study showed that on average, patients hospitalized at these top-performing hospitals had a 42.58 percent lower risk of experiencing one or more patient safety events compared to the bottom 15 percent of all hospitals.

The study estimated that if all of the hospitals evaluated for patient safety were to perform on the same level as those hospitals recognized by HealthGrades as a top-performer, 218,572 patient safety events would be eliminated and 22,590 deaths in Medicare beneficiaries would be avoided.

In addition, they estimated that nearly $2.1 billion would have been saved between 2006 and 2008.

HealthGrades said that portions of the healthcare reform bill look to adjust provider payments for “unnecessary readmissions and for high-cost common conditions acquired while in the hospital.” According to the study this means that facilities would no longer be paid for common safety indicators such as decubius ulcers or post-operative sepsis.

“Congress remains vigilant,” the report stated, in finding improved ways to reward performance, while attempting to punish facilities that exhibit a lack of patient and quality care.

“Avoiding mistakes by chance is no longer acceptable,” HealthGrades stated. “When patients enter the healthcare system, they entrust their health and their lives to their caregivers. The healthcare system must continue to put systematic safe practices in place to ensure that the system created to save them doesn’t unintentionally harm them,” the study authors concluded.