Medical Errors, Patient Safety and Adverse Events

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Medical Errors, Patient Safety and Adverse Events

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#MeToo and the Medical Profession

#MeToo and the Medical Profession began open discussion some months after 2017 when the movement began. Physician authors Holroyd-Laduc and Strauss write: “In the era of #MeToo, it is time for physicians to acknowledge that the medical profession is not immune to bullying, harassment and discrimination, and act to abolish these behaviours.” They further ask: “…why, with the MeToo movement, has there been no complaint against a prominent male physician?” Published in the Canadian Medical Association Journal (CMAJ) August 2018.

Chartbook on Patient Safety

The Patient Safety chartbook is part of the National Healthcare Quality and Disparities Report. It shows the progress made on lowering infections, hip or knee replacement adverse events, adverse drug events, cardiac bypass readmissions, home health care improvement, frequency of safety issues in medical offices, and patient safety culture. Rates shown to about 2020 (in some cases, data only to 2019; some of the culture surveys have data as recent as 2022). Published March 2023 by AHRQ.

Healthgrades – Hospital Awards for Patient Safety Excellence, 2023

Healthgrades 2023 awards for patient safety excellence lists top 10% (445) hospitals. These hospitals are distinguished for their patient safety, using 2019 to 2021 Medicare patient information. Hospitals were evaluated on 14 types of preventable patient safety incidents, such as leaving foreign objects behind during surgery, pressure ulcers [bedsores], accidental cuts during medical care; deep blood clots, collapsed lung pneumothorax, postoperative hip fracture, bloodstream infection, deaths after surgical complications, and postop sepsis. Annual study released March 2023 by Healthgrades.

How good is hospital care in the US?

Just how good is hospital care in the US, compared to other similar countries? The Health System Tracker by Peterson-KFF (Kaiser Family Foundation) provides trends among countries through 2020 or most recent year available. Topics include mortality rates, treatment outcomes, access, maternal deaths, hospitalization for chronic illnesses, number of C-sections, patient safety such as post-op complications for hip and knee replacements, post-operative sepsis after abdominal surgery; and medication and lab errors. With a few exceptions, the United States does not fare as well as comparable countries. Post-op sepsis after abdominal surgery, and 30-day mortality for heart attacks and strokes are lower in the U.S. than in comparable countries. Read the full report updated September 2021.

MedWatch – How to report serious adverse events to the FDA

MedWatch is FDA’s (Food and Drug Administration) site for consumers to report serious adverse reactions to medications, product quality and medical device problems

NQF 34 Safe Practices for Hospitals (pdf)

National Quality Forum’s (NQF) consensus on 34 patient safety practices for hospitals are summarized in this public document. Includes practices related to organizational culture; hand hygiene and preventing infection; information documentation, labeling, and communication; caregiver practices; discharge and medication reconciliation systems; more. Finalized 2010. Table of contents shows the 34 practices presented in the 400+ page report.

NQF Serious Reportable Events

The NQF list of Serious Reportable Events is sometimes called the list of Never Events. This report identifies 29 serious reportable events (SREs) considered preventable. Examples: wrong surgery; deaths or serious injury associated with medication error, or in a low-risk pregnancy, or due to a fall, or from failure to follow up on test results, or associated with certain MRI incidents; Stage 3 or 4 pressure ulcers. Applies to hospitals, clinics, nursing homes and ambulatory surgery centers. Updated edition; published by National Quality Forum (NQF)

Patient Safety Network, AHRQ

Many resources can be found at AHRQ’s Patient Safety Network website. In the redesigned site, you may have to dig to find what you’re looking for, but it is worth the effort to try. One of our favorite pages is the All Topics page for adverse events and other safety problems, shown here. There are a number of case studies and many journal articles. Includes studies and reports from the National Health Service of the United Kingdom. The Agency for Healthcare Research and Quality is a federal agency.

When Things Go Wrong: Responding to Adverse Events (pdf) Editor's Pick

“When Things Go Wrong: Responding to Adverse Events” was prepared by the Harvard teaching hospitals. It explains how to communicate with patients about serious medical errors and adverse events. Includes elements of a hospital incident policy, sample script for communicating with patients, supporting the staff, support to families; and extensive bibliography. Published by the Massachusetts Coalition for the Prevention of Medical Errors (macoalition.org), 42 pages, March 2006. Classic publication

Other Helpful Listings

National Practitioner Data Bank – 2022 Report

The National Practitioner Data Bank (NPDB) annual report for 2022 summarizes medical malpractice payment amounts. The average amount was $428,090 for physician claims. There were nearly 7,000 payments related to physician malpractice (MDs and DOs). Total payments in 2022 were almost $3 billion. The Data Analysis Tool shows total medical malpractice reports and payments by type of practitioner and by state. Consumers must calculate the average payment themselves. Of almost 800,000 people in the Data Bank, about 260,000 are physicians. Other practitioners include nurses, chiropractors, dentists, pharmacists, podiatrists and others. The Data Bank goes back to 1990. No individuals are named.

An older and more detailed pdf version of the report is available for 2012 only. It was published in 2014. The 2012 report reported that the time lag between incident and payment was typically 4 to 7 years. NPDB Report from 2012 is 78 pages.

Sentinel Event Definitions Editor's Pick

Find the definition of a sentinel event. The Joint Commission (which accredits healthcare organizations, formerly JCAHO) defines Sentinel Events for hospitals, ambulatory clinics, surgery centers, nursing homes, home care, assisted living, behavioral health facilities and other health care settings. Sentinel events reach patients and result in Death, Permanent harm, or Severe temporary harm and intervention required to sustain life. They require immediate investigation. The hospital definition was updated 2022.