WHAT WE FOUND

Twenty-five percent of Medicare patients experienced patient harm during their hospital stays in October 2018. Patient harm includes adverse events and temporary harm events.

Twelve percent of patients experienced adverse events, which are events that led to longer hospital stays, permanent harm, life-saving intervention, or death. In addition to the patients who experienced adverse events, 13 percent of patients experienced temporary harm events, which required intervention but did not cause lasting harm, prolong hospital stays, or require life-sustaining measures. Temporary harm events were sometimes serious and could have caused further harm if providers had not promptly treated patients.

• Categories of Harm Events. The most common type of harm event was related to medication (43 percent), such as patients experiencing delirium or other changes in mental status. The remaining events related to patient care (23 percent), such as pressure injuries; to procedures and surgeries (22 percent), such as intraoperative hypotension; and to infections (11 percent), such as hospital-acquired respiratory infections.
• Preventability of Harm Events. Physician-reviewers determined that 43 percent of harm events were preventable, with preventable events commonly linked to substandard or inadequate care provided to the patient. (The overall harm rate would be 13 percent if we were to include only events that our physician-reviewers determined were preventable.) Reviewers determined that 56 percent of harm events were not preventable and occurred even though providers followed proper procedures. Events were determined not preventable for several reasons, including that the patients were found to be highly susceptible to the events because of their poor health status.
• CMS’s Lists of Hospital-Acquired Conditions. CMS’s two policies on hospital-acquired conditions (HACs) create payment incentives for harm prevention by reducing payment for certain HACs. However, because the policies use narrowly scoped lists of HACs and employ specific criteria for counting harm events, they have limited effectiveness in broadly promoting patient safety. The lists did not cover most of the harm events that patients in our study experienced. Of the harm events we identified, only 5 percent were on CMS’s HAC Reduction Program list and only 2 percent were on CMS’s Deficit Reduction Act HAC list.
• Harm Events Resulting in Costs to Medicare. Nearly a quarter of Medicare patients who experienced harm events (23 percent), either preventable or nonpreventable, required treatment that led to additional Medicare costs. These events also potentially increased patient costs in the form of coinsurance and deductible payments. Costs were incurred during the sample hospital stay or for an additional hospital stay necessary to ameliorate the harm. Combined, we estimated the costs for all events to be in the hundreds of millions of dollars for October 2018.

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