The overall number of “adverse events” reported by Connecticut hospitals declined in 2016, but sexual assaults more than doubled, according to a new state report.
The Department of Public Health (DPH) report shows that hospitals reported a total of 431 medical errors in 2016, down about 5 percent from 456 in 2015.
But there were 24 reports of sexual abuse or assault on a patient or staff member within or on the grounds of a health care setting last year, up 140 percent from 10 cases in 2015, the report said. A majority—22 cases—happened at acute care hospitals. St. Vincent’s Medical Center in Bridgeport reported the most with 10, followed by Yale New Haven Hospital with seven, according to DPH.
Of the 24, seven were staff to patient, two were patient to staff, 10 were patient to patient and five were unknown perpetrator to patient. Fourteen of the reported assaults occurred in a psychiatric ward.
Reported cases of sexual assault could be rising, in part, because hospital employees feel more comfortable reporting when they suspect or see an assault, according to Mary Cooper, vice president and chief quality officer at the Connecticut Hospital Association.
“Zero sexual assaults is, obviously, where we want to be,” she said. “We are really promoting people coming forward and talking about these things. More reporting is always better because it lets us get to the root of what’s going on.”
Likewise, victims are increasingly feeling empowered to speak out about sexual assault, said Lisa Freeman, executive director of the nonprofit Connecticut Center for Patient Safety. Sexual assaults on patients are particularly troubling, she said, because “they are really vulnerable.”
DPH also reported that the number of wrong site surgeries rose from 13 to 18; wrong surgical procedures performed on a patient increased from one to six; and patient suicides, attempted suicides or self-harm resulting in serious injury rose from three to five. Perforations during open laparoscopic or endoscopic procedures resulting in death or serious injury rose from 49 to 58.
There were other serious medical errors that declined last year. Newborn deaths or serious injuries associated with labor and delivery in a low-risk pregnancy fell from five to two; deaths or serious injuries from falls dropped from 90 to 74; and deaths or injuries associated with the use of physical restraints or bedrails, declined from two to zero.
Pressure ulcers remained the most common reported adverse event, but the number of instances fell 19 percent from 230 reported in 2015 to 186 reported last year. Pressure ulcers, or bedsores, occur when prolonged pressure is put on the skin.
Hospitals throughout the state are working to reduce the occurrence of pressure ulcers, including assessing patients’ skin integrity and pressure ulcer risk soon after they arrive on site, Cooper said.
Most of the reported adverse events in Connecticut—387 of them, or 90 percent—happened at acute care or children’s hospitals and, as expected, some of the largest hospitals reported the highest totals. Yale New Haven reported 80; Bridgeport Hospital, 37; St. Vincent’s, 30; St. Francis Hospital and Medical Center, 29; and Hartford Hospital, 25.
No acute care hospital reported zero adverse events. Charlotte Hungerford Hospital, Rockville General Hospital and Windham Community Memorial Hospital reported one each, according to the report.
The hospitals with the highest rates based on patient days were Bristol Hospital at 62.9 per 100,000 patient days; Sharon Hospital at 50.3; and Milford Hospital at 45.2.
Freeman said the transparency of mandatory reporting, and the monetary fines it can bring, is helping in some areas, but more needs to be done.
“There are still too many problems,” she said. “No amount of medical harm is OK. There are things that we just shouldn’t have to see.”
If all hospital staff truly embraced high-reliability standards, she noted, there would be no incidents in which surgeries were performed on the wrong site, for instance.
“We still have bridges to cross,” she said. “This is just an ongoing issue.”
DPH invites facilities to submit comments about their efforts to improve outcomes. Seven facilities submitted comments in the most recent report.
St. Francis’ statement said the hospital has reduced pressure ulcers after its recent participation in a national study. In 2015 the hospital was chosen to participate in an Agency for Healthcare Research and Quality study that provided training and education on skin injuries related to pressure. The internal training continues.
In addition to the high-reliability standards every hospital has adopted, two new efforts began in 2017, Cooper said. One is an advisory council comprised of patients, family members and hospital staff that meets monthly to discuss ways hospitals can reduce harm; the other is a worker safety effort intended to address the ways workplace violence and witnessing patient harm can affect hospital staff.
“We are still focused on safety. That will never go away,” Cooper said.