A report issued yesterday by the Office of the Inspector General (OIG) (Times article, full report (pdf)) within the federal Department of Health and Human Services states that approximately 180,000 Medicare patients per year die as a result of an adverse medical event (defined as harm to a patient as a result of medical care).
A little less than half of all adverse events were deemed to be preventable, which means that each year about 90,000 Medicare patients alone die as a result of an adverse event that should not have happened. About 13.5% of Medicare patients experience an adverse event causing lasting harm and another 13.5% experience an adverse event causing “temporary” harm. So 27% of all Medicare patients in hospitals experience harm as a result of medical care. The cost to the Medicare system associated with adverse and temporary harm events is approximately $4.4 billion per year. Of that total, about $1.8 billion was spent on harm events that could have been prevented.
As we talk about reforming the payment and delivery system in order to contain costs and improve quality, there is much that can be done within hospitals that could save a lot of money and, even more importantly, lives.
Massachusetts and other states are already publicly reporting Serious Reportable Events (SREs), which are some of the most serious preventable adverse medical events. But according to the OIG report, SREs accounted for only 0.6% of the adverse events. While it is important to inform the public about these events, and to prohibit payment to hospitals for care needed following a preventable SRE, there is much more that needs to be done and that should also be publicly reported and not paid for. Hospitals also need to put in place protocols to prevent the events from happening-such as checklists for care to prevent surgical errors and complications and to prevent infections in the ICU, and, along with protocols such as these, transforming hospital cultures so that staff, patients and family members are encouraged to speak up when they think something is wrong and play a role in preventing adverse events from happening.