No One Wants To Be an “Adverse Event”

We cling to hope.  We assume our interaction with the health care system will work to our benefit and we can safely rely on the competence and good will of physicians, nurses, and other health professionals.  The problem is, we can’t.

Lots of evidence points to the stubborn pervasiveness of so-called “systemic” problems in quality of care.  A recent federal study, for example, found that 15,000 people on Medicare died in one month due to an adverse event–a medical error or other mistake, improper execution, or unintended consequence–suffered in a hospital.

photo of a man in a hospital bed with padding at his nose

Sinus Surgery

Another 119,000 hospitalized Medicare beneficiaries sustained a serious adverse event during the month, but survived it.  All told, one in seven hospital patients on Medicare suffered a serious adverse event–and an additional one in seven experienced an adverse event that caused only temporary harm.

The adverse events generated about $325 million in Medicare costs.  On an annual basis, this extrapolates (according to the study authors) to $4.4 billion in extra costs for the bankruptcy-skirting Medicare program.

There is no reason to believe that adverse events happen only to people on Medicare–if anything, Medicare is especially committed to improving quality and safety–or only to people in hospitals.

What this means is:  You are not immune from being linked to this grisly chain. You have to be on your guard.

Poor communication causes many, perhaps most, adverse events.  Most notably, medication errors result from misunderstandings about dosage, frequency, allergies, changes in orders, when to take the drug, how to administer it, and whether the patient is due for another dose.  Lapses in informing patients and staff about what they need to know also can cause dietary problems, infections, treatment complications, and all manners of bad things.

What can you do to keep from being a quality-of-care statistic (and not in a good way)?  If nothing else, take these three steps if you or a family member is in a hospital or other health facility:

  1. Ask questions about anything you don’t understand or that seems funny to you–a drug, test, or procedure that appears to differ from what a doctor or nurse had described, a change in routine that doesn’t make sense to you, or an intervention that appears to repeat something you just had.  Mention any contradictions between what different people tell you.
  2. Make sure that doctors, nurses, and other staff members identify themselves by name and function, so they can be contacted later as questions arise.  If possible, it’s a good idea to keep a list of these personnel.
  3. Repeat any orders that you are expected to carry out yourself, such as exercises or physical movements, and ask to have written out any instructions for what to do after discharge.

The federal study was conducted by the office of the Inspector General of the Department of Health and Human Services.  Using physicians as reviewers, it found that nearly half of the adverse events are preventable.

Especially discouraging is the apparent lack of progress since federal officials and hospitals took steps to reduce drastically the estimated 100,000 preventable hospital-related deaths that occur every year.  The federal study looked at hospitalizations that ended in October 2008.

In a comment on the study, the U.S. Agency for Healthcare Research and Quality (AHRQ) agreed that adverse events occur in hospitals at “an alarming rate.”  The Inspector General recommended that AHRQ and the Medicare program lead national efforts to improve quality, partly by following through on health reform.  Don’t wait for them.

(NOTE: This is my first post in almost four weeks.  I’ve been away, dealing with my own family health problems.  Now I plan to post frequently again.  Thanks for staying interested–and please share your stories and comments with me.)

Take care.

Photo credit:  krossbowAttribution.

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