Report Estimates 15,000 Medicare Monthly Adverse Event Deaths

Responding to the HHS inspector general's report, the leader of the Centers for Medicare & Medicaid Services' administrator, Dr. Donald Berwick, outlined numerous steps being taken to reduce hospital errors.

A new report from the HHS inspector general estimates that 15,000 Medicare patients in October 2008 experienced adverse events while hospitalized that contributed to their deaths. The cases in the random sample investigated by the IG's office included medication errors, bloodstream infections, aspirations, and a ventilator-associated pneumonia. An additional 13.5 percent of Medicare patients that month experienced an adverse event that resulted in temporary harm to them -- and here, again, medication errors were the most common cause, according to the report.

Significantly, the report's authors identified many adverse event incidents that were not on the National Quality Forum (NQF) list, which is important because that list is prominently used in states' adverse event reporting and as a measure of patient harm, the authors noted. They said only two of 18 adverse events they identified that resulted in serious disability or death of the patient were on the NQF list; both were medication errors. (The NQF Serious Reportable Events list is Appendix B of the report.)

Extrapolating the adverse event estimate to the $137 billion Medicare spent for inpatient care in FY2009, the report says adverse events cost $4.4 billion of that amount.

Physician reviewers determined 44 percent of adverse and temporary harm events were clearly or likely preventable, according to the report, which indicated hospital care associated with such events cost Medicare $324 million in October 2008. The report is based on a randomly selected sample of 785 beneficiaries among 999,645 who were discharged from acute care hospitals during that month.

The Centers for Medicare & Medicaid Services' administrator, Dr. Donald Berwick, provided a lengthy response that is included in the report. He discusses numerous steps CMS is taking to reduce hospital errors and notes eight hospital-acquired conditions (HACs) are being added to CMS' online Hospital Compare database: foreign object retained after surgery, air embolism, blood incompatibility, pressure ulcer (stages III and IV), falls and trauma, vascular catheter-associated infection, catheter-associated urinary tract infection, and manifestations of poor glycemic control.

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