Connecticut hospitals reported increases in patient deaths or serious injuries due to falls and medication errors in 2015 compared to 2014, but an overall drop in “adverse events,” according to a new state report.
The report, by the Department of Public Health (DPH), shows that the total number of medical errors dipped by 3 percent – from 472 in 2014, to 456 in 2015.
There were 90 instances when patients died or were seriously injured in falls, up from 78 in 2014. Seven falls that resulted in injury or death were reported at Yale New Haven Hospital, St. Vincent’s Medical Center and UConn’s John Dempsey Hospital. Falls were the second most common adverse event last year and accounted for nearly 20 percent of the total number of errors.
Medication errors that resulted in serious injury or patient death increased from one in 2014, to seven in 2015.
The number of deaths or serious injuries resulting from surgeries rose from 12 to 14; surgery performed on the wrong site dipped by two to 13 and there was one instance when a surgery was performed on the wrong patient, up from zero.
The number of patient suicides, attempted suicides or instances of self-harm also rose– from zero to three in hospitals.
Lisa Freeman, director of the nonprofit Connecticut Center for Patient Safety, said that despite improvements in some areas, any error is too many.
“These aren’t statistics, they’re people,” Freeman said. “For the people who are being harmed or dying because of medical harm, the overall decline doesn’t matter. They’re an event that should not be happening.”
Health care facilities have been required to report adverse events to DPH since 2002, and DPH notes in its report that adverse events are not necessarily the result of medical mistakes.
Roughly half of last year’s adverse events were serious pressure ulcers: 230 were reported in 2015, a decrease from 245 reported in 2014.
Pressure ulcers, also known as bedsores, result when prolonged pressure is put on the skin. The number of pressure ulcers reported statewide jumped in 2013, after health officials expanded the definition of the injury to include “unstageable” pressure ulcers.
Other serious errors also saw declines last year. Perforations during surgical procedures fell 31 percent, from 71 to 49, and retention of a foreign object following surgery dropped, from 24 to 19.
As expected, some of the state’s largest hospitals reported the highest totals of adverse events. Yale New Haven reported 76; Saint Francis, 50; St. Vincent’s, 43 and Hartford Hospital, 37. Johnson Memorial Hospital and Day Kimball Healthcare reported no adverse events. Sharon, Charlotte Hungerford and Windham Community Memorial hospitals reported one each.
The hospitals with the highest rates based on patient days were: Bristol Hospital, at 53.2 per 100,000 patient days; St. Vincent’s, at 39.3; Milford Hospital, at 33.5; Saint Francis, at 32.8; and William Backus Hospital, at 31.5.
In response to the report, Dr. Mary Cooper, vice president and chief quality officer at the Connecticut Hospital Association, said hospitals place a strong emphasis on patient safety. Most hospitals have adopted “high reliability” standards, and more than 50,000 health care workers statewide have been trained in recent years in how to better anticipate and prevent patient harm, she said.
“We have seen an extraordinary commitment to safety. A lot of the things that were put in place are starting to work,” she said. “(And) the techniques that are already in place will continue to show improvement.”
Hospital staffs continually are “looking to identify new solutions to old problems,” she said. She cited the example of reducing the time patients spend on Emergency Department gurneys, which has shown to lessen the occurrence of pressure ulcers.
Freeman said patients and their families should feel more empowered to voice concerns to medical staff when they feel a harmful situation may be imminent, and a broader culture shift is needed among patients and healthcare workers alike. Some lingering problems, like high rates of pressure ulcers, need more outside-the-box strategizing, she said.
In the report, DPH said that since hospitals self-report adverse events, there’s not necessarily a correlation between a relatively high number of events and a relatively poor level of care. More than half of 2015’s events, for instance, involved patients who were 65 and older, so hospitals that serve a larger elderly population could have higher numbers as a result.
The DPH report includes comments submitted by some hospitals, outlining steps they are taking to improve outcomes.
Saint Francis officials wrote that in 2014, the hospital became one of 10 nationwide to join an initiative aimed at preventing pressure ulcers that resulted in a drop by 75 percent of hospital-acquired pressure ulcers over a 12-month span.
St. Vincent’s officials said that the hospital had created a subgroup to review all patient falls, evaluate common causes of falls, and seek ways to improve outcomes. Hospital staff members also are working to improve surgical safety and best practices.
Among the state’s larger hospitals, Yale New Haven reported 55 pressure ulcers; Hartford Hospital and St. Francis each reported 31 pressure ulcers.
Yale reported seven fall-related deaths or serious injuries, four perforations during surgery that caused death or serious injury, and three medication errors, among other adverse events.
Hartford Hospital reported that three times, a foreign object was retained in a patient following surgery or another procedure, one surgery was performed on the wrong site and one perforation occurred during a procedure.
Saint Francis reported four perforations, one surgery performed on the wrong site, one surgery done on the wrong patient, and two deaths or injuries due to incorrectly used devices.
Leapfrog, a national organization which strives to make improvements in the quality and safety of health care through transparency, this week released its fall 2016 Hospital Safety Grades. In Connecticut, six hospitals: UConn’s John Dempsey, St. Francis, Griffin, Stamford, Greenwich and Sharon received top A-grades.
A grade of B was given to Day Kimball, Backus, Middlesex, Bristol, St. Vincent’s and Charlotte Hungerford hospitals.
Windham, John Memorial, Rockville, Hartford, MidState, Hospital of Central Connecticut, Yale New Haven, Milford, Waterbury, Bridgeport and Norwalk hospitals were all given a C-grade. St. Mary’s, Danbury and Manchester hospitals were given Ds.