Statistics

Medical error statistics are alarming, yet they provide us with the sense of urgency we need – to collectively work together to reduce errors and eliminate preventable deaths from taking place in our hospitals. Take a look at the statistics we’ve collected, share them amongst your network, and most importantly, learn about the considerable levels of error that exist in acute care so that we can turn these harrowing facts into opportunities for effective change and patient safety improvement together.

Healthcare-Associated Infections

As many as 28,000 patients die from CLABSI annually in U.S. intensive care units (AHRQ, n.d.). CLABSIs have a mortality rate of 12-25% (CDC, 2011). CLABSIs in the US alone cost $2.3 billion annually (Sagana & Hyzy, 2013).¹

AHRQ, n.d.

CDC, 2011

Sagana & Hyzy, 2013

Healthcare-Associated Infections

Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay, and prolonged use of a urinary catheter is a risk factor for developing a CAUTI (CDC, 2021). Catheter acquired urinary tract infection is one of the most common healthcare acquired infections. 70–80% of these infections are attributable to use of an indwelling urethral catheter (Nicolle, 2014).²

CDC, 2021

Nicolle, 2014

Hand Hygiene

Over a 16-month follow-up period with an implemented infection-control program, hand-hygiene compliance increased from 41.0% (2235/5454) to 50.5% (3246/6428)³

WHO, 2020

Hand Hygiene

In a study, it showed that over a 4-year period when hand-hygiene improved from 47.6% (1349/2834) to 66.2% (1701/2569), the prevalence of health-care-associated infections decreased from 16.9% to 9.9%⁴

WHO, 2020

Hand Hygiene

In a study with exceptionally high initial hand-hygiene compliance of 82.6%, compliance increased to 95.9% while the rate of health-care-associated infections fell by 6.0% during the 17-month study period⁵

WHO, 2020

Ventilation Management

A study identified a strong association between hospital mortality and NVHAP, with patients who acquired NVHAP having an 8.4 times greater odds of death (95% CI, 5.6-12.5)⁶

A Case-Control Study Assessing the Impact of Non Ventilator Hospital-Acquired Pneumonia on Patient Outcomes – CHEST (chestnet.org).

Ventilation Management

NV-HAP among individuals residing in long-term care facilities and the incidence of pneumonia in this health care setting which accounts for up to 18% of all persons admitted to acute care hospital for pneumonia⁷

Non-ventilator health care-associated pneumonia (NV-HAP): Long-term care – ScienceDirect

Racial Disparities & Biases in Healthcare

Racial and ethnic minorities receive lower-quality health care than white people—even when insurance status, income, age, and severity of conditions are comparable⁸

Bridges, K. M. (n.d.). Implicit Bias and Racial Disparities in Health Care. Retrieved from https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/racial-disparities-in-health-care/

Racial Disparities & Biases in Healthcare

Black, American Indian, and Alaska Native (AI/AN) women are two to three times more likely to die from pregnancy-related causes than white women – and this disparity increases with age⁹

Petersen EE, Davis NL, Goodman D, et al. Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016. MMWR Morb Mortal Wkly Rep 2019;68:762–765. DOI: http://dx.doi.org/10.15585/mmwr.mm6835a3

Racial Disparities & Biases in Healthcare

An emerging body of research indicates that patients from minority groups are at higher risk of patient safety events, which are events that could have or did result in harm to the patient, compared to the mainstream population.¹⁰

10.

Chauhan, A., Walton, M., Manias, E. et al. The safety of health care for ethnic minority patients: a systematic review. Int J Equity Health 19, 118 (2020). https://doi.org/10.1186/s12939-020-01223-2

Surgical and Procedural Safety

With over 200 million surgical procedures performed worldwide each year, there is high risk for error – according to WHO, errors in surgical procedures are at an all-time unacceptable high¹¹

11.

Kim, F. J., da Silva, R. D., Gustafson, D., Nogueira, L., Harlin, T., & Paul, D. L. (2015). Current issues in patient safety in surgery: a review. Patient Safety in Surgery, 9(1), 9–26. https://doi.org/10.1186/s13037-015-0067-4

Surgical and Procedural Safety

There are 1 million deaths each year due to post-surgical complications, 50 percent of which are preventable.¹²

12.

Weiser, T., & Gawande, A. (2015). Essential Surgery: Disease Control Priorities. Excess Surgical Mortality: Strategies for Improving Quality of Care, 1. https://www.ncbi.nlm.nih.gov/books/NBK333498/

Surgical and Procedural Safety

Globally, nearly 7 million patients suffer from post-surgical complications each year¹³

13.

Impact of Medical Errors on Seniors

The number of deaths from unsafe care in patients over 65 stands at around 130,000 per year¹⁴

14.

AHRQ. 2019. “AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014-2017.”

Impact of Medical Errors on Seniors

Hospitalized older patients appear to be particularly susceptible to nosocomial infections. The incidence of hospital-acquired nosocomial infections in older patients ranges from 5.9 to 16.9 per 1000 hospital days¹⁵

15.

Rothschild, J. M., Bates, D. W., & Leape, L. L. (2000). Preventable Medical Injuries in Older Patients. Archives of Internal Medicine, 160(18), 2717. doi:10.1001/archinte.160.18.2717

Impact of Medical Errors on Seniors

In a more recent study of patient safety indicators conducted by AHRQ [Agency for Healthcare Research and Quality], the highest rates of patient safety events related to errors were found among individuals between the ages of 65 to 74 years¹⁶

16.

Tsilimingras, D., Rosen, A. K., & Berlowitz, D. R. (2003). Review Article: Patient Safety in Geriatrics: A Call for Action. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 58(9). doi:10.1093/gerona/58.9.m813

Hand-Off Communications

Of the many improvements from implementing hand off communications, verbal communication and quality was the most to be improved¹⁷

17.

Smith, C., Buzalko, R., Anderson, N., Michalski, J., Warchol, J., Ducey, S., & Branecki, C. (2018). Evaluation of a Novel Handoff Communication Strategy for Patients Admitted from the Emergency Department. Western Journal of Emergency Medicine, 19(2), 372–379. https://doi.org/10.5811/westjem.2017.9.35121

Hand-Off Communications

Surprisingly, only 23 percent of physicians from an acute care hospital setting were able to identify the nurses attending to their patient. Vice versa, only 42 percent of nurses from the same study were able to identify the physician for their patient.^18,19

18.

Friesen, M., White, S., & Byers, J. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Handoffs: Implications for Nurses, 1. https://www.ncbi.nlm.nih.gov/books/NBK2649/

19.

Hand-Off Communications

Errors in communication breakdowns have been seen to account for nearly 43 percent of surgical incidents, and two-thirds of these incidents were due to hand off related errors.²⁰

20.

Friesen, M., White, S., & Byers, J. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Handoffs: Implications for Nurses, 1. https://www.ncbi.nlm.nih.gov/books/NBK2649/

Workplace Dangers/Injuries in Healthcare vs Other Industries

According to the Bureau of Labor Statistics, the likelihood of injury or illness resulting in days away from work is higher in hospitals than in construction and manufacturing—two industries that are traditionally thought to be relatively hazardous²¹

21.

Occupational Safety and Health Administration. (n.d.). Understanding the Problem. Retrieved from https://www.osha.gov/dsg/hospitals/understanding_problem.html

Workplace Dangers/Injuries in Healthcare vs Other Industries

In all healthcare areas, employees face the risk of being a victim of violence. Workplace violence is one of the most complex and dangerous hazards faced by resident doctors, nurses and helpers²²

22.

Mohanty, A., Kabi, A., & Mohanty, A. P. (2019). Health problems in healthcare workers: A review. Journal of family medicine and primary care, 8(8), 2568–2572. https://doi.org/10.4103/jfmpc.jfmpc_431_19

Workplace Dangers/Injuries in Healthcare vs Other Industries

Healthcare is the most dangerous industry for injuries and illnesses, with 653,000 nurses, aides, orderlies and others injured or falling ill every year²³

23.

Lincoln, T., & Wrightson, K. (2013, July 17). Health Care Workers Unprotected: Insufficient Inspections and Standards Leave Safety Risks Unaddressed (Rep.). Retrieved https://www.citizen.org/wp-content/uploads/health-care-workers-unprotected-2013-report.pdf

Pain Management

In the 1800’s, treatment of pain was very minimal – pain was to be approached as an existential experience and was only viewed as a mere consequence of getting older.²⁴

24.

Tompkins, D. A., Hobelmann, J. G., & Compton, P. (2017). Providing chronic pain management in the “Fifth Vital Sign” Era: Historical and treatment perspectives on a modern-day medical dilemma. Drug and Alcohol Dependence, 173, S11–S21. https://doi.org/10.1016/j.drugalcdep.2016.12.002

Pain Management

Nearly 100 billion dollars are spent each year in the United States for pain management related expenses and opioid dependency.²⁵

25.

Dydyk, A., Yarrarapu, S., & Conermann, T. (2020). Stat Pearls. Chronic Pain, 1. https://www.ncbi.nlm.nih.gov/books/NBK553030/

Pain Management

The number of Americans living with chronic pain exceeds 100 million and pain is thus the most common reason for seeking medical attention²⁶

26.

Healthcare Worker Related Statistics

Physician burnout is an under-recognized and under-reported problem, characterized by a state of mental exhaustion, depersonalization, and a decreased sense of personal accomplishment. It affects more than 60% of Health Care Workers (HCWs)²⁷

27.

Healthcare Worker Related Statistics

Physicians have a higher suicide rate compared with other graduates and the general population, both among males and females.²⁸

28.

Hem, E., Haldorsen, T., Aasland, O. G., Tyssen, R., Vaglum, P., & Ekeberg, Ø. (2004). Suicide rates according to education with a particular focus on physicians in Norway 1960–2000. Psychological Medicine, 35(6), 873–880. doi: 10.1017/s0033291704003344

Healthcare Worker Related Statistics

44.0% of nursing staff members have been bullied at some point in their working lives²⁹

29.

Ariza-Montes, A., Muniz, N., Montero-Simó, M., & Araque-Padilla, R. (2013). Workplace Bullying among Healthcare Workers. International Journal of Environmental Research and Public Health, 10(8), 3121–3139. doi: 10.3390/ijerph10083121

Medication Safety

Annually, the estimated cost due for looking after patients affected by medication errors is 40 billion dollars³⁰

30.

Tariq, R., Vashisht, R., & Scherbak, Y. (2020). Stat Pearls. Medication Errors, 1. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Medication Safety

Each year, anywhere between 7,000 and 9,000 lives are lost due to errors in medication administration and prescription³¹

31.

Tariq, R., Vashisht, R., & Scherbak, Y. (2020). Stat Pearls. Medication Errors, 1. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Medication Safety

In the United states alone, nearly 3 million American elderly are admitted to nursing homes annually due to drug-related problems; thereby, indicating a strong need for thorough and full-proof medication management.³²

32.

Marek, K., & Antel, L. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Medication Management of the Community-Dwelling Older Adult, 1. https://www.ncbi.nlm.nih.gov/books/NBK2670/

COVID-19

It is estimated that 12.5 to 44% of COVID-19 cases were nosocomial – acquired in hospitals by patients who were admitted for other reasons.^33,34

33.

Rickman, H. M., Rampling, T., Shaw, K., Martinez-Garcia, G., Hail, L., Coen, P., … & Houlihan, C. F. (2020). Nosocomial transmission of COVID-19: a retrospective study of 66 hospital-acquired cases in a London teaching hospital. Clinical Infectious Diseases.

34.

Carter, B., Collins, J. T., Barlow-Pay, F., Rickard, F., Bruce, E., Verduri, A., … & Stechman, M. J. (2020). Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial Study (COVID in Older PEople). Journal of Hospital Infection, 106(2), 376-384.

Obstetric Safety

The risk of maternal death is 4 times higher in cesarean births, while amniotic fluid embolism is 2-3 times more likely. Other serious complications occur in cesarean birth at an overall rate that is 3 times higher than vaginal birth (2.7% vs. 0.9%)³⁵

35.

Liu, S., Liston, R. M., Joseph, K., & Heaman, M. (2007). Maternal Mortality and Severe Morbidity Associated with Low-risk Planned Cesarean Delivery Versus Planned Vaginal Delivery at Term. Canadian Medical Association Journal, 176(4), 455-460

Obstetric Safety

Approximately 1.2 million c-sections are performed annually³⁶

36.

Centers for Disease Control. (2019). Cesarean Delivery Rate by State. Retrieved from:

https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm

Obstetric Safety

Studies show that between 50-70% of deaths due to severe preeclampsia are preventable³⁷

37.

Aukes, A. M., Wessel, I., Dubois, A. M., Aarnoudse, J. G., & Zeeman, G. G. (2007). Self-Reported Cognitive Functioning in Formerly Eclamptic Women. Obstetrical & Gynecological Survey, 197(4)

Obstetric Safety

According to the most recent mortality data reported to the CDC in 2011-2012, PPH caused 11% of pregnancy-related deaths in the U.S.³⁸

38.

Berg, C., Atrash, H., Koonin, L., Tucker, M. (1996). Pregnancy-related Mortality in the United States 1987-1990. Obstetrics & Gynecology, 88(2)

Obstetric Safety

In developing countries with high rates of maternal mortality, nearly one-fourth of deaths are attributable to PPH³⁹

39.

AbouZahr, C. (1998). Antepartum and Postpartum Hemorrhage. Retrieved from http://www.scirp.org/(S(vtj3fa45qm1ean45vvffcz55))/reference/ReferencesPapers.aspx? ReferenceID=1569986

Obstetric Safety

Unnecessary C-sections also pose long-term health risks including subsequent uterine scar rupture, abnormal placentation, increased risk of hemorrhage, and hysterectomy where there is an exponential increase in such complications with the number of prior cesareans.⁴⁰

40.

Tihtonen, K. and Nyberg, R. (2014). [Long-term effects of uterine cesarean section scar]. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24730196.

Obstetric Safety

In the United States, one-third of patients give birth surgically and international experts have identified this high cesarean rate as a significant maternal health safety issue. Short term complications from this form of invasive surgery include blood loss, infection, and venous thrombosis with the small but real risk of maternal mortality.⁴¹

41.

Lothian, J. (2014). Safe Prevention of the Primary Cesarean Delivery: ACOG and SMFM Change the Game. The Journal of Perinatal Education, 23(3), pp.115-118.

Obstetric Safety

Internationally, C-sections are on the rise ranging from an average of 40.5% in Latin America/Caribbean area to 7.3% in Africa⁴²

42.

Betran, A. (2016). The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. (published 5 February 2016).

Obstetric Safety

Harvard’s Shah points out that C-sections are major surgery, with all of the risks of any hospital procedure. “Unnecessary C-sections may be responsible for up to 20,000 major surgical complications a year, including everything from sepsis [a life-threatening complication of certain infections] to hemorrhage to organ injury,” he says.⁴³

43.

Haelle, Tara. (2017). Your Biggest C-Section Risk May Be Your Hospital.

Nasogastric Tube Placement and Verification

In one day at 63 institutions, 24% of hospitalized infants and children needed NGTs, including an orogastric (OG) (tube placed through the mouth), nasogastric (NG), or transpyloric (tube placed in the upper small bowel) tube⁴⁴

44.

Lyman, B., Kemper, C., Northington, L. D., Yaworski, J. A., Wilder, K., Moore, C., … Irving, S. (2015). Use of Temporary Enteral Access Devices in Hospitalized Neonatal and Pediatric Patients in the United States. Journal of Parenteral and Enteral Nutrition, 40(4), 574–580. doi:10.1177/0148607114567712

Nasogastric Tube Placement and Verification

In infants, 59% NGTs are misplaced, with most tubes misplaced in the esophagus⁴⁵

45.

October, T. W. and Hardart, G. E. (2009). Successful Placement of Postpyloric Enteral Tubes using Electromagnetic Guidance in Critically Ill Children. Pediatric Critical Care Medicine, 10(2), 196–200

Nasogastric Tube Placement and Verification

In adult patients, NGT misplacement causes serious harm in 1 to 3% of tubes placed⁴⁶

46.

Gilbertson, H. R., Rogers, E. J. and Ukoumunne, O. C. (2011). Determination of a Practical pH Cutoff Level for Reliable Confirmation of Nasogastric Tube Placement. Journal of Parenteral and Enteral Nutrition, 35(4), 540–544. doi:10.1177/0148607110383285

Nasogastric Tube Placement and Verification

Between 2005 and March 2011 the NPSA was notified of 21 deaths and 79 cases of harm due to misplaced NG tubes.⁴⁷

47.

Medical Protection. (2012). Nasogastric Tube Errors.

Medication Safety

The Drug Information Service at University of Utah Health Care (UUHC), which partners with the ASHP to manage its drug shortage program, tracked a total of 211 drug shortages in 2010—the highest number recorded to date in a single year.⁴⁸

48.

Ventola, C. Lee. (2011). U.S. National Library of Medicine, National Institutes of Health. The Drug Shortage Crisis in the United States.

Falls and Mobility

Injuries related to falls can result in an additional 6.3 hospital days with the cost for a serious fall with injury averaging $14,056 per patient⁴⁹

49.

Health Research & Educational Trust. (2016, October). Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare Project. Retrieved from http://www.hpoe.org/Reports-HPOE/2016/preventing-patient-falls.pdf

Falls and Mobility

Patients who have a serious injury related to a fall during a hospital stay average 6–12 days of additional hospital time and incur higher costs than comparison patients ($13,316 more, on average) compared to their peers⁵⁰

50.

Bouldin, E. L., Andresen, E. M., Dunton, N. E., Simon, M., Waters, T. M., Liu, M., … Shorr, R. I. (2013). Falls among adult patients hospitalized in the United States: prevalence and trends. Journal of patient safety, 9(1), 13–17. doi:10.1097/PTS.0b013e3182699b64

Falls and Mobility

Approximately half of the 1.6 million nursing home residents in the United States fall each year⁵¹

51.

AHRQ. (2019, September). Falls. Retrieved from https://psnet.ahrq.gov/primer/falls

Falls and Mobility

Epidemiologic studies have found that falls occur at a rate of 3–5 per 1000 bed-days, and the Agency for Healthcare Research and Quality estimates that 700,000 to 1 million hospitalized patients fall each year.⁵²

52.

AHRQ. (2019, September). Falls. Retrieved from https://psnet.ahrq.gov/primer/falls

Falls and Mobility

According to the Kings Fund, falls are one of the most causes of preventable harm for aging adults in Europe⁵³

53.

Maybin, J., Charles, A., & Honeyman, M. (2016). Understanding quality in district nursing services. The King’s Fund, London

Falls and Mobility

Each year, somewhere between 700,000 and 1,000,000 people in the United States fall in the hospital. A fall may result in fractures, lacerations, or internal bleeding, leading to increased health care utilization. Research shows that close to one-third of falls can be prevented.⁵⁴

54.

Preventing Falls in Hospitals. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

Falls and Mobility

The new numbers are being released in conjunction with the 9th Falls Prevention Awareness Day, sponsored by the National Council on Aging (NCOA). The observance addresses the growing public health issue and promotes evidence-based prevention programs and strategies to reduce the more than 27,000 fall deaths in older adults each year.⁵⁵

55.

Evaluate. (2016) Falls are leading cause of injury and death in older Americans. Centers for Disease Control and Prevention. [online] http://evaluategroup.com/Universal/View.aspx?type=Story&id=661184

Falls and Mobility

In 2014 alone, older Americans experienced 29 million falls causing seven million injuries and costing an estimated $31 billion in annual Medicare costs, according to a new report published by the Centers for Disease Control and Prevention in this week’s Morbidity and Mortality Weekly Report (MMWR)⁵⁶

56.

CDC. (2016). Falls are leading cause of injury and death in older Americans. [online] Available at: https://www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html.

Falls and Mobility

According to the CDC, Every second of every day in the United States an older adult falls, making falls the number one cause of injuries and deaths from injury among older Americans.⁵⁷

57.

CDC. (2016). Falls are leading cause of injury and death in older Americans. [online] Available at: https://www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html.

Mental Health

Up to 47% of mental health care providers have experienced violence at work⁵⁸

58.

Nolan, P., Dallender, J., Soares, J., Thomesen, S., & Arnetz, B. (1999). Violence in Mental Health Care: The Experiences of Mental Health Nurses and Psychiatrists. Journal of Advanced Nursing. 30(4) 934-941

Mental Health

Seclusion rates in an acute inpatient psychiatry unit can reach as high as 31%, with the most common indicator of seclusion being risk to others (74%) followed by risk to self (61%) and risk of absconding (55%)⁵⁹

59.

Tunde-Ayinmode, M., & Little, J. (2004) Use of Seclusion in a Psychiatric Acute Inpatient Unit. Australasian Psychiatry. 12(4) 347-351. DOI: 10.1080/j.1440-1665.2004.02125.x

Mental Health

About 1,500 suicides take place at inpatient psychiatric units in the U.S. each year—over 70% by hanging⁶⁰

60.

Mills, P.D., King, L., Watts, B., & Hemphill, R. (2013) Inpatient Suicide on Mental Health Units in Veterans Affairs (VA) Hospitals: Avoiding Environmental Hazards. The American Journal of Medicine 35(5) 528-536. Retrieved from: http://dx.doi.org/10.1016/j.genhosppsych.2013.03.021

Embolic Events

25-30% of healthy adults have patent foramen ovale (PFO), and most of these are asymptomatic and undiagnosed⁶¹

61.

Hagen, P.T., Scholz, D.G., Edwards, W.D. (1984). Incidence and Size of Patent Foramen Ovale During the First 10 Decades of Life: An Autopsy Study of 965 Normal Hearts. Mayo Clinic Proceedings, 59(1), 17–20. doi:10.1016/s0025-6196(12)60336-x

Embolic Events

The estimated number of annual VTE cases is 3.9 million in high-income countries and 6.0 million in low- and middle-income countries⁶²

62.

Raskob, G. E. et al. (2014). A major contributor to global disease burden. Arteriosclerosis, Thrombosis, and Vascular Biology, 34, 2363-2371

Post-Operative Delirium in Older Adults

Up to 65% older post-operative patients suffer some form of delirium following a surgical procedure, especially if requiring ICU admission⁶³

63.

Marcantonio, E. (2017). Delirium in Hospitalized Older Adults. New England Journal of Medicine, 377(15)

Post-Operative Delirium in Older Adults

It is estimated that up to 40% of hospital-related episodes of delirium are preventable⁶⁴

64.

Inouye, S., Westendorp, R., & Saczynski, J. (2014). Delirium in elderly people. Lancet, 383(9920)

Post-Operative Delirium in Older Adults

The cost of an episode of acute care is increased 2.5 times by the occurrence of delirium, increasing the cost of healthcare in the United States by over $125 billion dollars every year⁶⁵

65.

Inouye, S., Westendorp, R., & Saczynski, J. (2014). Delirium in elderly people. Lancet, 383(9920).; Brown, C. H., Laflam, A., Max, L., Lymar, D., Neufeld, K. J., Tian, J., … Hogue, C. W. (2016). The Impact of Delirium After Cardiac Surgical Procedures on Postoperative Resource Use. The Annals of Thoracic Surgery, 101(5), 1663–1669. doi: 10.1016/j.athoracsur.2015.12.074

Post-Operative Delirium in Older Adults

10% to 30% of hospitalized patients age 65 and older have an episode of delirium during their stay⁶⁶

66.

Arnold, E. (2005). Sorting Out the 3 D’s: Delirium, Dementia, Depression. Learn How to Sift Through Overlapping Signs and Symptoms So You Can Help Improve an Older Patient’s Quality of Life. Holistic Nursing Practice,19(3)

Post-Operative Delirium in Older Adults

Delirium is characterized by altered mental status and hallmarked by a fluctuating and fleeting attention span⁶⁷

67.

Brown, L. J., Fordyce, C., Zaghdani, H., Starr, J. M., & Maclullich, A. M. (2010). Detecting deficits of sustained visual attention in delirium. Journal of Neurology, Neurosurgery & Psychiatry,82(12), 1334-1340. doi:10.1136/jnnp.2010.208827

Post-Operative Delirium in Older Adults

Delirium is defined as an acute change or fluctuation in the course of a patient’s mental status, plus inattention and either disorganized thinking or an altered level of consciousness⁶⁸

68.

Inouye SK, van Dyck CH, Alessi CA, et al: Clarifying confusion: The confusion assessment method. Ann Intern Med 1990; 113: 941–948

Post-Operative Delirium in Older Adults

Many healthcare professionals acknowledge the severity of delirium in patients and many even admit to its misdiagnosis, confusion with other conditions, or mistreatment⁶⁹

69.

Ely, E. W., Stephens, R. K., Jackson, J. C., Thomason, J. W., Truman, B., Gordon, S., . . . Bernard, G. R. (2004). Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: A survey of 912 healthcare professionals*. Critical Care Medicine,32(1), 106-112. doi:10.1097/01.ccm.0000098033.94737.84

Post-Operative Delirium in Older Adults

Early identification of delirium in patients can avoid inappropriate early discharge, thereby leading to successful outcomes through extended observation and care⁷⁰

70.

Breitbart W., Bruera E., Chochinov H.& Lynch M. (1995) Neuropsychiatric syndromes and psychological symptoms in patients with advanced cancer. Journal of Pain and Symptom Management 10, 131–141

Neonatal Safety

Each year, an estimated 2,000 infants die or are undiagnosed in the U.S. and some 300,000 infants die or are undiagnosed globally⁷¹

71.

Salvi, S. (2016, September). Faculty of 1000 evaluation for Global, Regional, and National Age- sex Specific All-cause and Cause-specific Mortality for 240 Causes of Death, 1990-2013: a Systematic Analysis for the Global Burden of Disease Study 2013. Faculty of 1000 Ltd. doi:10.3410/f.725286838.793523287

Neonatal Safety

More than 30% of CCHD deaths have been attributed to late or missed diagnosis⁷²

72.

Chang, R.-K. R., Gurvitz, M. and Rodriguez, S. (2008). Missed Diagnosis of Critical Congenital Heart Disease. Archives of Pediatrics & Adolescent Medicine, 162(10), 969. doi:10.1001/archpedi.162.10.969

Neonatal Safety

Screenings show that the number of deaths from CCHD is closer to 120 each year⁷³

73.

Grosse, S. D., Riehle-Colarusso, T., Gaffney, M., Mason, C. A., Shapira, S. K., Sontag, M. K., … Iskander, J. (2017). CDC Grand Rounds: Newborn Screening for Hearing Loss and Critical Congenital Heart Disease. MMWR Morb Mortal Wkly Rep, 66, 888–890

Neonatal Safety

Before newborn screening programs were introduced in the U.S. in 2012, it was estimated that between 70-100 infants died each year from late-diagnosed CCHD⁷⁴

74.

Govindaswami, B., Jegatheesan, P. and Song, D. (2012). Oxygen Saturation Screening for Critical Congenital Heart Disease. NeoReviews, 13(12), e724–e731. doi:10.1542/neo.13-12-e724)

Neonatal Safety

CCHD causes most of the deaths due to CHD that occur within the first year of life⁷⁵

75.

Hoffman, J. I. E. and Kaplan, S. (2002). The Incidence of Congenital Heart Disease. Journal of the American College of Cardiology, 39(12), 1890–1900. doi:10.1016/s0735-1097(02)01886-7

Neonatal Safety

Each year, nearly 40,000 infants are born with CHD in the U.S., and 1.35 million infants are born with CHD globally⁷⁶

76.

Hoffman, J. I. E. and Kaplan, S. (2002). The Incidence of Congenital Heart Disease. Journal of the American College of Cardiology, 39(12), 1890–1900. doi:10.1016/s0735-1097(02)01886-7

Neonatal Safety

CHD is the most common birth defect, affecting approximately 8 in 1,000 live-born infants⁷⁷

77.

Reller, M. D., Strickland, M. J., Riehle-Colarusso, T., Mahle, W. T. and Correa, A. (2008). Prevalence of Congenital Heart Defects in Metropolitan Atlanta 1998-2005. The Journal of Pediatrics, 153(6), 807–813. doi:10.1016/j.jpeds.2008.05.059

Neonatal Safety

At 5 years of age, motor impairment, cognitive impairment, and severe hearing loss that is 3-4 times more common in children with severe ROP, typically caused by newborn over-use of supplemental oxygen, than those without it⁷⁸

78.

Neonatal Safety. (2019, December 4). Retrieved from https://patientsafetymovement.org/actionable-solutions/challenge-solutions/neonatal-safety/

Airway Safety

Even for intubations performed by hospital-based transport teams, 70% of neonates required multiple attempts, compared to 30% of the pediatric population⁷⁹

79.

Smith, K. A., Gothard, M. D., Schwartz, H. P., Giuliano, J. S., Jr., Forbes, M., & Bigham, M. T. (2015). Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport. Prehosp Emerg Care, 19(1), 17-22. doi:10.3109/10903127.2014.964888

Airway Safety

In the hospital setting, first attempt intubation success in neonates is <50%⁸⁰

80.

Sauer, C. W., Kong, J. Y., Vaucher, Y. E., Finer, N., Proudfoot, J. A., Boutin, M. A., & Leone, T. A. (2016). Intubation attempts increase the risk for severe intraventricular hemorrhage in preterm infants—A retrospective cohort study. The Journal of Pediatrics, 177, 108-113. doi:http://dx.doi.org/10.1016/j.jpeds.2016.06.051

Airway Safety

The incidence of failed intubations in children in out-of-hospital settings, defined by 3 or more unsuccessful attempts, is as high as 58%, and these or other major intubation difficulties are associated with higher odds of cardiac arrest⁸¹

81.

Hansen, M., Meckler, G., Lambert, W., Dickinson, C., Dickinson, K., Van Otterloo, J., & Guise, J. M. (2016). Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS. BMJ Open, 6(11), e012259. doi:10.1136/bmjopen-2016-012259

Airway Safety

Unplanned Extubations happen in over 7% of patients who undergo mechanical ventilation in the ICU and the complications of unplanned extubations result in over $4 billion in healthcare costs⁸²

82.

da Silva, P. S. L. and Fonseca, M. C. M. (2012). Unplanned Endotracheal Extubations in the Intensive Care Unit. Anesthesia & Analgesia, 114(5), 1003–1014. doi:10.1213/ane.0b013e31824b0296

Airway Safety

Failed intubations occur in as high as 38% of patients in non-physician intubator field cases and as high as 22% of patients in physician intubator field cases⁸³

83.

Crewdson, K., Lockey, D.J., Roislien, J., Lossius, H.M., & Rehn, M. (2017). The success of pre-hospital tracheal intubation by different pre-hospital providers: A systematic literature review and meta-analysis. Critical Care, 21(31), https://doi.org/10.1186/s13054-017-1603-7

Airway Safety

The incidence of failed airways can be as high as 1 in 50-100 in ED and ICU settings and the occurrence of death or brain damage have been reported to be 38-fold (ED) to 58-fold (ICU) higher compared to the operating room setting with anesthesia⁸⁴

84.

Cook, T. M. and MacDougall-Davis, S. R. (2012). Complications and Failure of Airway Management. British Journal of Anaesthesia, 109(suppl 1), i68–i85. doi:10.1093/bja/aes393

Airway Safety

A majority of respondents felt that drug shortages had compromised patient care. Most (71%) were unable to provide patients with the recommended drug or treatment for their condition due to shortages, and nearly half (47%) thought that this resulted in patients receiving a less effective drug. Also, three-quarters (75%) of respondents stated that patient treatments had been delayed because of drug shortages⁸⁵

85.

Drug Shortages Continue to Compromise Patient Care. (2018, January 11). Retrieved from https://www.ismp.org/resources/drug-shortages-continue-compromise-patient-care

Medication Safety

Ninety-four percent of respondents reported rationing or restricting drugs in short supply. Examples included establishing criteria for using products, restricting access to drugs via override in automated dispensing cabinets (ADCs), and providing kits for emergency drugs. Thirty percent of all respondents said they have used a drug in short supply outside its specific labeling to help extend its use, such as keeping expired products (without FDA-extended dating) in code carts⁸⁶

86.

Drug Shortages Continue to Compromise Patient Care. (2018, January 11). Retrieved from https://www.ismp.org/resources/drug-shortages-continue-compromise-patient-care

Medication Safety

The number of errors more than doubled from 3,065 cases in 2000 to 6,855 cases in 2012⁸⁷

87.

Hayes, K. (2017, July 24). Medication Errors Rise, with 1.3M People Injured Yearly. Retrieved from https://www.aarp.org/health/drugs-supplements/info-2017/medication-errors-rise-fd.html

Medication Safety

Adverse drug events (ADEs) account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation.⁸⁸

88.

Silva, B. A. D., & Krishnamurthy, M. (2016). The alarming reality of medication error: a patient case and review of Pennsylvania and National data. Journal of Community Hospital Internal Medicine Perspectives, 6(4), 31758. doi: 10.3402/jchimp.v6.31758

Sepsis

Mortality from sepsis increases by as much as 8% for every hour that treatment is delayed. As many as 80% of sepsis deaths could be prevented with rapid diagnosis and treatmen⁸⁹

89.

Kumar, A., Roberts, D., Wood, K. E., Light, B., Parrillo, J. E., Sharma, S., … Cheang, M. (2006). Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock*. Critical Care Medicine, 34(6), 1589–1596. doi: 10.1097/01.ccm.0000217961.75225.e9

Sepsis

CDC estimates that 1.7 million adults in the U.S. develop sepsis every year⁹⁰

90.

Data & Reports. (2016, August 23). Retrieved from https://www.cdc.gov/sepsis/datareports/index.html

Sepsis

85% [of sepsis] occurs in low- or middle-income countries⁹¹

91.

Zick, M. (2020, January 16). The Lancet: Sepsis Associated with 1 in 5 Deaths Worldwide, Double Prior Estimates – Children and Poor Regions Hit Hardest. Retrieved from https://www.worldsepsisday.org/news/2020/1/16/the-lancet-sepsis-associated-with-1-in-5-deaths-worldwide-double-prior-estimates-children-and-poor-regions-hit-hardest-global-burden-disease-study-kristina-rudd

Sepsis

2 out of every 5 cases [of sepsis] are in children under 5⁹²

92.

Zick, M. (2020, January 16). The Lancet: Sepsis Associated with 1 in 5 Deaths Worldwide, Double Prior Estimates – Children and Poor Regions Hit Hardest. Retrieved from https://www.worldsepsisday.org/news/2020/1/16/the-lancet-sepsis-associated-with-1-in-5-deaths-worldwide-double-prior-estimates-children-and-poor-regions-hit-hardest-global-burden-disease-study-kristina-rudd

Sepsis

1 in every 5 deaths worldwide are associated with sepsis⁹³

93.

Sepsis

Twice as many people are dying from sepsis worldwide than previously estimated, with 48.9 million cases and 11 million deaths in 2017 alone⁹⁴

94.

Healthcare-Associated Infections

HAIs alone are among the top ten causes of death in the US, according to AHRQ⁹⁵

95.

Health Care-Associated Infections. (n.d.). Retrieved from https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/hais/index.html

Healthcare-Associated Infections

The annual estimate for CAUTI costs is approximately $565 million with 8,205 deaths per year⁹⁶

96.

Healthcare-Acquired Infections (HAIs). (n.d.). Retrieved from https://patientcarelink.org/improving-patient-care/healthcare-acquired-infections-hais/

Healthcare-Associated Infections

Patients who acquire infections in the hospital are not only twice as likely to die, but spend, on average, almost 7 extra days in the hospital and are five times more at risk for readmission⁹⁷

97.

Healthcare-Acquired Infections (HAIs). (n.d.). Retrieved from https://patientcarelink.org/improving-patient-care/healthcare-acquired-infections-hais/

Healthcare-Associated Infections

In US hospitals, according to the CDC estimates, HAIs account for 1.7 million infections and 99,000 associated deaths annually. Of these infections, 32 percent are urinary tract infections, 22 percent are surgical site infections, and 14% are bloodstream infections⁹⁸

98.

Klevens, R. M., Edwards, J. R., Richards, C. L., Horan, T. C., Gaynes, R. P., Pollock, D. A., & Cardo, D. M. (2007). Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports, 122(2), 160–166. doi: 10.1177/003335490712200205

Healthcare-Associated Infections

An estimated 1.7 million healthcare-associated infections occur each year leading to 99,000 deaths.⁹⁹

99.

Center for Disease Control and Prevention. (n.d.). Preventing Healthcare-Associated Infections. Retrieved https://www.cdc.gov/washington/~cdcatWork/pdf/infections.pdf

Creating a Foundation for Safe and Reliable Care

4 in 10 patients harmed in healthcare¹⁰⁰

100.

Finnegan, J. (2020, January 28).
4 in 10 patients harmed by medical errors in primary and outpatient settings. Retrieved from https://www.fiercehealthcare.com/practices/medical-errors-globally-as-many-as-4-10-patients-harmed-primary-and-outpatient-settings

Creating a Foundation for Safe and Reliable Care

Up to one-third of patients are unintentionally harmed during a hospital stay¹⁰¹

101.

James, J. T. (2013).
A New Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 9(3), pp. 122–128; Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., . . . James, B. C. (2011). ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. Health Affairs,30(4), 581-589. doi:10.1377/hlthaff.2011.0190

Person and Family Engagement

At the local level, collaboration between the public health sector, hospitals, and outcome improvement experts reduced hospital readmissions by 7,000 in Minnesota between 2011 and 2013, enabling patients in Minnesota to spend 28,120 nights sleeping in their own beds instead of the hospital, and helped reduce healthcare costs by more than $55 million¹⁰²

102.

AHRQ. (2016). National Patient Safety Efforts Save 125,000 Lives and Nearly $28 Billion in Costs. Retrieved from https://www.ahrq.gov/news/newsroom/press-releases/national-patient-safety-efforts-save-lives.html.

Person and Family Engagement

One study found that the rate of adverse events decreased by almost 30% after a multicomponent intervention involving structured team communication as well as patient engagement tools and training on patient safety in the intensive care unit¹⁰³

103.

Dykes PC ; Rozenblum R ; Dalal A; et al. Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study. Crit Care Med. 2017; 45: e806-e813. https://psnet.ahrq.gov/resources/resource/31062

Person and Family Engagement

Implementing patient and family engagement strategies has led to fewer hospital-acquired infections, reduced medical errors, reduced serious safety events, and increased patient satisfaction scores¹⁰⁴

104.

Issue Brief: Patient and Family Engagement: A Partnership for Culture Change: A Report of the NCIOM Task Force on Patient and Family Engagement. (2015). North Carolina Medical Journal, 76(3), pp.197-200

Person and Family Engagement

Blood transfusions also are associated with longer hospital stays – slightly more than two extra days on average¹⁰⁵

105.

Department of Anesthesia. (2019, January 23). Retrieved from https://medicine.uiowa.edu/anesthesia/content/anemia-management-improves-patient-safety-lowers-costs

*General Patient Safety Statistics

Breakdowns in communication were the leading cause of sentinel events (death or serious harm to a patient that requires further review) reported to The Joint Commission between 1995 and 2006¹⁰⁶

106.

The Joint Commission. (2013). Sentinel Events (SE). Retrieved from https://www.jointcommission.org/assets/1/6/CAMH_2012_Update2_24_SE.pdf

*General Patient Safety Statistics

The Agency for Healthcare Research and Quality (AHRQ) reports that nearly half of hospital staff believe patient information is lost during transfers across hospital units or during shift changes¹⁰⁷

107.

Sorra, J. and Nieva, V. F. (2004). Hospital Survey on Patient Safety Culture. Agency for Healthcare Research and Quality

*General Patient Safety Statistics

With 67% of patients facing unintended medication discrepancies in the hospital and more than 40% of medication reconciliation errors resulting from miscommunications in handoffs, medication safety has become a leading priority for patients and caregivers¹⁰⁸

108.

Tam, V. C. (2005). Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. Canadian Medical Association Journal, 173(5), 510–515. doi: 10.1503/cmaj.045311

*General Patient Safety Statistics

It is estimated that as high as 80 percent of medical bills contain errors¹⁰⁹

109.

Gooch, Kelly. (2016). “Medical billing errors growing, says Medical Billing Advocates of America.” Becker’s Hospital Review. Retrieved from https://www.beckershospitalreview.com/finance/medical-billing-errors-growing-says-medical-billing-advocates-of-america.html

*General Patient Safety Statistics

According to the WHO, 1 in 10 patients may be harmed while receiving care in developed countries while receiving hospital care¹¹⁰

110.

World Health Organization. (2018). 10 facts on patient safety. [online] Available at: http://www.who.int/features/factfiles/patient_safety/en/

*General Patient Safety Statistics

According the WHO, European data, mostly from European Union Member States, consistently show that medical errors and health-care related adverse events occur in 8% to 12% of hospitalizations. For example, the United Kingdom Department of Health, in its 2000 report An organization with a memory, estimated about 850 000 adverse events a year (10% of hospital admissions). Spain (in its 2005 national study of adverse events) and France and Denmark have published incidence studies with similar results.¹¹¹

111.

World Health Organization. A brief synopsis on patient safety. (2010).

*General Patient Safety Statistics

According to the WHO, Statistics show that strategies to reduce the rate of adverse events in the European Union alone would lead to the prevention of more than 750 000 harm-inflicting medical errors per year, leading in turn to over 3.2 million fewer days of hospitalization, 260 000 fewer incidents of permanent disability, and 95 000 fewer deaths per year.¹¹²

112.

Euro.who.int. (2018). Data and statistics. [online] Available at: http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics

*General Patient Safety Statistics

According to the WHO, Patient safety is a serious global public health issue. There is a 1 in 1,000,000 chance of a traveler being harmed while in an aircraft. In comparison, there is a 1 in 300 chance of a patient being harmed during health care.¹¹³

113.

World Health Organization. (2018). 10 facts on patient safety. [online] Available at: http://www.who.int/features/factfiles/patient_safety/en/

Medication Errors

31% to 39% medication administration error rate in pediatric emergency departments.¹¹⁴

114.

190114 – Get to Zero Infographic. (n.d.). Retrieved from http://www.ebroselow.com/190114-get-to-zero-infographic/

Medication Errors

4 in 10 children suffer medication errors during an emergency.¹¹⁵

115.

190114 – Get to Zero Infographic. (n.d.). Retrieved from http://www.ebroselow.com/190114-get-to-zero-infographic/

Medication Errors

1.3 million people injured from adverse drug events in 2017 alone¹¹⁶

116.

190114 – Get to Zero Infographic. (n.d.). Retrieved from http://www.ebroselow.com/190114-get-to-zero-infographic/

Medication Safety

“The most common reasons for shortages were manufacturing problems (28%) and product discontinuation (20%). The most frequently represented pharmacologic-therapeutic categories were central nervous system agents (24%) and serums, toxoids, and vaccines (17%).”¹¹⁷

117.

Fox, E., & Tyler, L. (2003). Managing drug shortages: Seven years’ experience at one health system. American Journal of Health-System Pharmacy,60(3).

Medication Safety

“The number of prescription drug shortages in the country nearly tripled between 2005 and 2010.”¹¹⁸

118.

Kweder, S. L., & Dill, S. (2012). Drug Shortages: The Cycle of Quantity and Quality. Clinical Pharmacology & Therapeutics,93(3), 245-251. doi:10.1038/clpt.2012.235

Medication Safety

“Manufacturers are required to notify the FDA of quality problems; however, drug shortages or discontinuations are often caused by a business decision or other factors that don’t require FDA notification.”¹¹⁹

119.

Ventola, C. L. (2011). The Drug Shortage Crisis in the United States: Causes, Impact, and Management Strategies. Pharmacy and Therapeutics, 36(11), 740–757.

Post-Operative Delirium in Older Adults

“Delirium is associated with multiple serious outcomes including increased morbidity, length of hospital stay, healthcare costs, institutionalization, and mortality”¹²⁰

120.

Greer, N., Rossom, R., Anderson, P., MacDonald, R., Tacklind, J., Rutks, I., & Wilt, T. (2011). Delirium: Screening, Prevention, and Diagnosis – A Systematic Review of the Evidence. Europe PMC.

Post-Operative Delirium in Older Adults

“Patients who are admitted to the hospital with delirium have mortality rates 10% to 26% higher than similar patients without delirium at the time of admission”¹²¹

121.

Goldstein, N. E., & Morrison, R. S. (2013). Evidence-based practice of palliative medicine. Philadelphia: Elsevier/Saunders.

Collaborative Care Planning

In one study, about 74% of patients with major depression achieved a 50% reduction in depression symptoms under collaborative care compared to 44% for patients receiving usual care.¹²²

122.

Katon, W., Von Korff, M., Lin, E., Walker, E., Simon, G. E., Bush, T., . . . Russo, J. (1995). Collaborative Management to Achieve Treatment Guidelines: Impact on Depression in Primary Care. JAMA, 273(13), 1026. doi:10.1001/jama.1995.03520370068039

Collaborative Care Planning

A few studies on the effects of collaborative care suggest that it is more effective than usual care in improving anxiety for up to 2 years.¹²³

123.

Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD006525. DOI: 10.1002/14651858.CD006525.pub2.

Collaborative Care Planning

Collaborative care for anxiety and depression is one of the most well-evaluated interventions in mental health in primary care.¹²⁴

124.

Collaborative Care Planning

Collaborative care programs have been shown to be both clinically-effective and cost-effective for a variety of mental health conditions, in a variety of settings, using several different payment mechanisms.¹²⁵

125.

Unützer, J., Harbin, H., Schoenbaum, M., & Druss, B. (2013). The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes. Health Home.

Embolic Events

Recent mortality rates due to arterial emboli range from 4 to 15%.¹²⁶

126.

Lyaker, M. R., Tulman, D. B., Dimitrova, G. T., Pin, R. H., & Papadimos, T. J. (2013). Arterial embolism. International Journal of Critical Illness and Injury Science, 3(1), 77–87. http://doi.org/10.4103/2229-5151.109429

Embolic Events

Aortic atherosclerotic plaque is one of the leading sources of embolic disease.¹²⁷

127.

Kronzon I., Tunick P.A. Aortic atherosclerotic disease and stroke. Circulation. 2006;114:63–75.

Embolic Events

Complications of arterial embolism are a leading cause of disability and death in the United States.¹²⁸

128.

Lyaker, M. R., Tulman, D. B., Dimitrova, G. T., Pin, R. H., & Papadimos, T. J. (2013). Arterial embolism. International Journal of Critical Illness and Injury Science, 3(1), 77–87. http://doi.org/10.4103/2229-5151.109429

Reducing Unnecessary Cesarean Deliveries

The rate of caesarean section births in the U.S. was 32.7 percent in 2013, which is above the WHO’s ideal “medically necessary” target of 10-15 percent.¹²⁹

129.

Gibbons, L., Belizán, J. M., Lauer, J. A., Betrán, A. P., Merialdi, M., & Althabe, F. (2010). The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage (World Health Report, Rep.). World Health Organization. Retrieved from http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf

Air Embolism

The cost for each occurrence is an average of $66,007 per air embolism.¹³⁰

130.

Rowland, Hudson T. (2009) “When Never Happens: Implications of Medicare’s Never-Event Policy,” Marquette Elder’s Advisor: Vol. 10: Iss. 2, Article 7.

Air Embolism

The mortality rate of central line related air emboli death ranges from 23% to 50%.¹³¹

131.

Feil, M. (2015). Preventing Central Line Air Embolism. AJN, American Journal of Nursing,115(6), 64-69. doi:10.1097/01.naj.0000466327.76934.a0

Air Embolism

The incidence of massive air embolism in cardiac bypass procedures is between 0.003% and 0.007% with 50% having adverse outcomes.¹³²

132.

Hammon, J.W., Hines, M.H. Extracorporeal Circulation. In: Cohn LH, editor. Cardiac Surgery in the Adult. 4th ed. New York: McGraw-Hill; 2012.

Reducing Unnecessary Cesarean Deliveries

Using C-section data reported by 1,318 hospitals through the voluntary 2016 Leapfrog Hospital Survey, Leapfrog found that over 55% of reporting hospitals had excessive rates of C-sections. That means that far too many women are undergoing a major abdominal surgery without medical necessity.¹³³

133.

The Leapfrog Group. Rate of C-Sections. http://www.leapfroggroup.org/ratings-reports/rate-c-sections

Reducing Unnecessary Cesarean Deliveries

Recent statistics from 150 countries show a global C-section rate of 18.6% for all births. Almost 1 in 5 women around the world will give birth via C-section.¹³⁴

134.

McCulloch, Sam. (2016). Highest C-section Rates by Country. (Cited 2016 December 9).

Reducing Unnecessary Cesarean Deliveries

With a projected C-section rate of 19.5 percent in 2012, 250 of every 100,000 mothers died during childbirth. A death rate more common in countries with C-section rates below 7 percent.¹³⁵

135.

Palmer, Katie M. (2015). How Many C-Sections is Too Many C-Sections?. (Cited 2015 December 1).

Reducing Unnecessary Cesarean Deliveries

C-sections are a major surgery and encompass all the risks of any hospital procedure. Unnecessary C-sections may be responsible for up to 20,000 major surgical complications a year, including everything from sepsis, a life-threatening complication, to hemorrhage or organ injury.¹³⁶

136.

Haelle, Tara. (2017). Your Biggest C-Section Risk May Be Your Hospital. (Cited 2017 May 16).

Falls and Mobility

Each year an estimated 646, 000 individuals die from falls globally. Of which over 80% are in low and middle-income countries.¹³⁷

137.

World Health Organization. (2017). Falls. (Cited 2017 August).

Falls and Mobility

The rate of patient falls in ambulatory surgery centers was found to be 0.124 per 1,000 admissions, according to the ASC Quality Collaboration Report: 3rd Quarter 2013.¹³⁸

138.

Vaidya, Anuja. (2014). Three Statistics on Rate of Patient Falls Per 1,000 ASC Admissions. (Cited 2014 January 27).

Falls and Mobility

Between 700,000 and 1,000,000 people experience falls in U.S. hospitals annually. 30 to 50% of those falls result in an injury.¹³⁹

139.

MCN Healthcare. (2016). Patient Falls Top TJC’s 2Q 2016 List of Reported Sentinel Events. (Cited 2016 August 8).

Falls and Mobility

Accidental falls are among the most common incidents reported in hospitals, complicating approximately 2% of hospital stays. Rates of falls in U.S. hospitals range from 3.3 to 11.5 falls per 1,000 patient days.¹⁴⁰

140.

U.S. National Library of Medicine, National Institutes of Health. (2014). Falls Among Adult Patients Hospitalized in the United States: Prevalence and Trends. (Cited 2014)

Medication Safety

A shortage of the injectable antibiotic streptomycin was reported in 15 countries in 2010, with 11 more countries predicting their stocks would run out before they could be replenished.¹⁴¹

141.

Gray, Andy. Manasse, Henri R. (2012). Shortages of Medicines: A Complex Global Challenge. (Cited 2012 March).

Medication Safety

One recent survey found that 89% of hospitals implicated a drug shortage as a potential cause for a medical error or patient safety issue. In 2012, an Associated Press article reported 15 deaths over the course of 15 months directly attributed to drug shortages.¹⁴²

142.

Academic Emergency Medicine, Official Journal of the Society for Academic Emergency Medicine. (2014). Critical Drug Shortages: Implications for Emergency Medicine.

Medication Safety

The Drug Information Service at the University of Utah Health Care (UUHC), which partners with the ASHP to manage its drug shortage program, tracked a total of 211 drug shortages in 2010—the highest number recorded to date in a single year.¹⁴³

143.

Ventola, C. Lee. (2011). U.S. National Library of Medicine, National Institutes of Health. The Drug Shortage Crisis in the United States. (cited 2011 November).

Medication Safety

According to a recent infographic supplied by the FDA, quality issues affect 64% of all drug shortages. A lack of raw material, a boost in drug demand (as has occurred in the past with flu vaccines and antiviral treatments) and lack of financial incentive to continue manufacturer production, can affect drug availability.¹⁴⁴

144.

Drugs.com. Drug Shortage Statistics in the U.S. and the FDA Response. https://www.drugs.com/drug-shortages/stats

Nasogastric Tube Placement and Verification

Thousands of feeding tubes are inserted daily without incident. However, there is a small risk that the nasogastric feeding tube can be misplaced into the lungs during insertion, or move out of the stomach at a later stage. In 2009, feeding into the lung from a misplaced nasogastric tube became a “never event” in England.¹⁴⁵

145.

NHS Salisbury. (2011). Insertion and Care of Nasogastric Tubes. (Cited 2011 March).

Nasogastric Tube Placement and Verification

In studying over 2,000 feeding tube insertions, Sorokin et al. (2006) determined 1.3 to 2.4 percent of NG tubes were malpositioned and 28 percent of those resulted in respiratory complications (e.g. pneumonia, pneumothorax).¹⁴⁶

146.

Children’s Hospital Association, Child Health Patient Safety Organization. (2012). A Patient Experienced a SERIOUS SAFETY EVENT. (cited 2012 August).

Nasogastric Tube Placement and Verification

Between 2005 and 2011 the NPSA was notified of 21 deaths and 79 cases of harm due to misplaced NG tubes.¹⁴⁷

147.

Medical Protection. (2012). Nasogastric Tube Errors. (cited 2012).

Nasogastric Tube Placement and Verification

Every year, nearly 500,000 nasogastric (NG) and percutaneous endoscopic gastrostomy (PEG) tubes and suction tubes are misplaced, which result in severe complications or death.¹⁴⁸

148.

AHC Media. (2015). Misplaced NG tubes a major patient safety risk. (cited 2015 April 1).

Person and Family Engagement

The global mHealth solutions market (including apps, mHealth services, and connected medical devices) is expected to grow to $59.15 billion by 2020, surging by an annual rate of 33.4% during that time.¹⁴⁹

149.

Iafolla, Teresa. (2016). 21 Fascinating Patient Engagement Stats. (Cited 2016 February 15).

Person and Family Engagement

A 2015 study showed that 45% of adults are at risk for limited health literacy. That is nearly half of patients.¹⁵⁰

150.

Hayley, Kenslea. (2016). Five Patient Engagement Statistics You Can’t Afford to Ignore. (cited 2016 August 11).

Person and Family Engagement

In a recent Gallup survey, when patients agree that they “knew what to expect after surgery” 72% were extremely satisfied with surgery results, compared to only 39% satisfaction among those who did not know what to expect.¹⁵¹

151.

Hayley, Kenslea. (2016). Five Patient Engagement Statistics You Can’t Afford to Ignore. (cited 2016 August 11).

Person and Family Engagement

A recent poll showed just under 60 percent of folks, even in higher age brackets, are willing to engage electronically with care providers.¹⁵²

152.

Hayley, Kenslea. (2016). Five Patient Engagement Statistics You Can’t Afford to Ignore. (cited 2016 August 11).

Mental Health

11.7 beds remain per 100,000 people. This means there are fewer state hospital beds per capita than at any time since before the nation stopped criminalizing mental illness in the 1850s.¹⁵³

153.

Fuller, D. A., & Sinclair, E. G. J., Quanbeck, C., & Snook, J.(2016). Going, going, gone: Trends & consequences of eliminating state psychiatric beds, 2016. Treatment Advocacy Center.

Mental Health

Nearly 20% of the hospital beds for the nation’s most severely ill and dangerous psychiatric patients were eliminated in the last 5 years.¹⁵⁴

154.

Dieleman, J. L., Baral, R., Birger, M., Bui, A. L., Bulchis, A., Chapin, A., … & Lavado, R. (2016). US spending on personal health care and public health, 1996-2013. JAMA, 316(24), 2627-2646.

Mental Health

Adults living with serious mental illness die on average 25 years earlier than other Americans, largely due to treatable medical conditions.¹⁵⁵

155.

National Association of State Mental Health Program Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: Parks, J., et al. – See more at: http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers#sthash.emQpo9jn.dpuf

Mental Health

Mood disorders such as depression are the 3rd most common cause of hospitalization in the U.S. for both youth and adults ages 18 to 44.¹⁵⁶

156.

Wier, LM (Thompson Reuters), et al. HCUP facts and figures: statistics on hospital-based care in the United States, 2009. Web. Rockville, Md. Agency for Healthcare Research and Quality, 2011. Retrieved March 5, 2013, from http://www.hcup-us.ahrq.gov/reports.jsp.

Mental Health

Serious mental illness costs America $193.2 billion in lost earning per year.¹⁵⁷

157.

Insel, T.R. (2008). Assessing the Economic Costs of Serious Mental Illness. The American Journal of Psychiatry. 165(6), 663-665 – See more at: http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers – sthash.F0CmiSZV.dpuf

Mental Health

Approximately 60% of adults and almost ½ of youth ages 8 to 15 with a mental illness received no mental health services in the previous year.¹⁵⁸

158.

National Institutes of Health, National Institute of Mental Health. (n.d.). Statistics: Any Disorder Among Adults. Retrieved March 5, 2013, from: http://www.nimh.nih.gov/statistics/1ANYDIS_ADULT.shtml

Mental Health

Approximately 20% of youth ages 13 to 18 experience severe mental disorders in a given year.¹⁵⁹

159.

Mental Health

25% of Americans experience mental illness in a given year.¹⁶⁰

160.

Centers for Disease Control and Prevention. (2011). CDC Report: Mental Illness Surveillance Among Adults in the United States. Retrieved from https://www.cdc.gov/mentalhealthsurveillance/fact_sheet.html

Mental Health

In 2005, there were 17 public psychiatric beds available per 100,000 population compared to 340 per 100,000 in 1955. Thus, 95 percent of the beds available in 1955 were no longer available in 2005.¹⁶¹

161.

Torrey, E. F., Estsminger, K., Geller, J., Stanley, J., & Jaffe, D. J. (2015). The shortage of public hospital beds for mentally ill persons. 2008. The Treatment Advocacy Center. Arlington, VA.

Embolic Events

In Europe, there are 544,000 VTE-related deaths every year.¹⁶²

162.

Heit, JA. Poster 68 presented at: American Society of Hematology, 47th Annual Meeting, Atlanta, GA, December 10-13, 2005.

Embolic Events

In the United States, there are 100,000 – 300,000 VTE-related deaths every year.¹⁶³

163.

Office of the Surgeon General (US. (2008). The Surgeon General’s call to action to prevent deep vein thrombosis and pulmonary embolism.

Embolic Events

Every year, there are approximately 10 million cases of VTE worldwide.¹⁶⁴

164.

Jha, A. K., Larizgoitia, I., Audera-Lopez, C., Prasopa-Plaizier, N., Waters, H., & Bates, D. W. (2013). The global burden of unsafe medical care: Analytic modelling of observational studies. BMJ Quality & Safety, 22(10), 809-815.

Embolic Events

In the U.S. and Europe, VTE-related events kill more people than AIDS, breast cancer, prostate cancer and motor vehicle crashes combined.¹⁶⁵

165.

Cohen AT, Agnelli G, Anderson FA, et al. Venous thromboembolism (VTE) in Europe. Thromb Haemost. 2007;98:756-764.

Obstetric Safety

11.1% of pregnancy-related deaths in the U.S. resulted from “hypertensive disorders of pregnancy,” including preeclampsia.¹⁶⁶

166.

https://www.nichd.nih.gov/news/resources/spotlight/Pages/101812-preeclampsia.aspx

Obstetric Safety

Pre-eclampsia is the cause of 15% of premature births in the U.S.¹⁶⁷

167.

Jeyabalan, A. (2013). Epidemiology of preeclampsia: Impact of obesity. Nutrition Reviews, 71(0 1), 10.1111/nure.12055. http://doi.org/10.1111/nure.12055

Obstetric Safety

Obstetric hemorrhage and pre-eclampsia account for over 70% of cases of severe maternal morbidity.¹⁶⁸

168.

California Maternal Quality Care Collaborative. Project Overview/FAQs. Retrieved from: https://www.cmqcc.org/resource/2900/download

Obstetric Safety

Over the past decade, severe maternal morbidity in the United States has increased by 75% for complications associated with delivery and, specifically, 114% for postpartum hemorrhage.¹⁶⁹

169.

Callaghan, W.M., Creanga, A.A., Kuklina, E.V. Severe maternal morbidity among delievey and postpartum hospitalizations in the United States. Obstet Gynecol 2012;120:1029-36.

Obstetric Safety

125,000 women a year are affected by postpartum hemorrhage.¹⁷⁰

170.

The AWHONN Postpartum Hemorrhage Project. Maternal Morbidity & Mortality.

Obstetric Safety

Postpartum hemorrhage is a leading cause of pregnancy-related complications, with an estimated 2.9% of the women who give birth in the U.S. will bleed too much.¹⁷¹

171.

The AWHONN Postpartum Hemorrhage Project. Maternal Morbidity & Mortality.

Obstetric Safety

Approximately 50% of hospital risk management budgets are allocated for obstetric events, and birth-related events account for more than 75% of claims paid in amounts over $1 million.¹⁷²

172.

Perinatal Safety Intervention Program (PSIP): Design and Development: AHRQ’s 2012 Annual Conference Slide Presentation. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2012/track_a/106_hendrich_kamerow/kamerow.html

Obstetric Safety

Anemia is estimated to be responsible for 17-46% of cases in maternal death.¹⁷³

173.

Fawzia Ahmed Habib, Intessar Sultan and Shaista Salman (2012). Morbidity and Mortality in Anemia, Anemia, Dr. Donald Silverberg (Ed.), ISBN: 978-953-51-0138-3, InTech, Available from: http://www.intechopen.com/books/anemia/morbidity-and-mortality-in-anemia

Obstetric Safety

Over the past decade, severe maternal morbidity in the United States has increased by 75% for complications associated with delivery and, specifically, 114% for postpartum hemorrhage.¹⁷⁴

174.

Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012;120:1029–36.

Obstetric Safety

Obstetric hemorrhage and preeclampsia account for over 70% of cases of severe maternal morbidity.¹⁷⁵

175.

California Maternal Quality Care Collaborative. Project Overview/FAQs. Retrieved from: https://www.cmqcc.org/resource/2900/download

Obstetric Safety

The United States is the one of the only countries where maternal deaths and injuries have increased.¹⁷⁶

176.

Gaskin, I. M. (2008). Maternal Death in the United States: A Problem Solved or a Problem Ignored? The Journal of Perinatal Education, 17(2), 9–13. http://doi.org/10.1624/105812408X298336

Obstetric Safety

Every 10 minutes, a woman in the United States almost dies of pregnancy-related complications.¹⁷⁷

177.

The AWHONN Postpartum Hemorrhage Project. Maternal Morbidity & Mortality.

Obstetric Safety

30-40% of “near misses” and severe maternal morbidities may be preventable through changes in patient, health care provider, and system factors.¹⁷⁸

178.

In-hospital Cardiac Arrest

CPR only provides 10 – 30% of normal blood flow to the heart and 30 – 40% of normal blood flow to the brain when performed according to guidelines, therefore CPR must be delivered at the highest quality possible.¹⁷⁹

179.

Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenson, J., De Caen, A. R., Bhanji, F., … & Aufderheide, T. P. (2013). Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital a consensus statement from the American Heart Association. Circulation, 128(4), 417-435.

Sepsis

Sepsis was the most expensive condition treated in U.S. hospitals, costing more than $20 billion in 2011.¹⁸⁰

180.

Torio, C. M., & Andrews, R. M. (2013). National inpatient hospital costs: the most expensive conditions by payer, 2011.

Sepsis

Sepsis is the number one cause of death in the ICU in the U.S.¹⁸¹

181.

Mayr, F. B., Yende, S., & Angus, D. C. (2014). Epidemiology of severe sepsis. Virulence, 5(1), 4–11. http://doi.org/10.4161/viru.27372

Sepsis

Sepsis mortality rate is 30-40%.¹⁸²

182.

Fleischmann, C., Thomas–Rueddel, D. O., Hartmann, M., Hartog, C. S., Welte, T., Heublein, S., … Reinhart, K. (2016). Hospital Incidence and Mortality Rates of Sepsis: An Analysis of Hospital Episode (DRG) Statistics in Germany From 2007 to 2013. Deutsches Ärzteblatt International, 113(10), 159–166. http://doi.org/10.3238/arztebl.2016.0159

Sepsis

The Agency for Healthcare Research and Quality lists sepsis as the most expensive condition treated in U.S. hospitals, costing more than $20 billion in 2011.¹⁸³

183.

Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Statistical Brief No. 160 August 2013. National inpatient hospital costs: the most expensive conditions by payer, 2011.

Sepsis

Severe sepsis is a growing problem in the United States with estimates of up to 3,000,000 hospitalizations per year.¹⁸⁴

184.

Wang, H., Shapiro, N., Angus, D. and Yealy, D. (2007). National estimates of severe sepsis in United States emergency departments. Critical Care Medicine, 35(8), pp.1928-1936.

Sepsis

At least 10 to 15% of sepsis deaths are avoidable by vaccination, hygienic measures, early detection, and prompt treatment measures.¹⁸⁵

185.

World Sepsis Day PRNewswire. http://www.world-sepsis-day.org. September 11, 2014.

Sepsis

Severe sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, killing one in four and often more, and increasing in incidence.¹⁸⁶

186.

AMN Healthcare Education Services. (2014). Management of Sepsis in the Adult. Retrieved from: https://lms.rn.com/getpdf.php/2057.pdf

Airway Safety

Unplanned extubation occurs in over 7% of patients undergoing mechanical ventilation in the Intensive Care Unit and the complications of unplanned extubations result in over $4 billion healthcare costs.¹⁸⁷

187.

da Silva, P. S. L., & Fonseca, M. C. M. (2012). Unplanned endotracheal extubations in the intensive care unit: Systematic review, critical appraisal, and evidence-based recommendations. Anesthesia & Analgesia, 114(5), 1003- 1014.

Airway Safety

The incidence of perioperative complications is greater in patients with obstructive sleep apnea (OSA).¹⁸⁸

188.

Liao, P., Yegneswaran, B., Vairavanathan, S. et al. Can J Anesth/J Can Anesth (2009) 56: 819. doi:10.1007/s12630-009-9190-y.

Airway Safety

Sentinel events from respiratory depression are caused by wrong dosing 47% of the time and improper monitoring 29% of the time.¹⁸⁹

189.

Joint Commission. (2012). Sentinel Event Alert Issue 49: Safe use of opioids in hospitals. August 8, 2012.

Airway Safety

68% of all failure-to-rescue deaths occur among surgical inpatients with treatable complications, pressure ulcers, post-operative respiratory failure, and post-operative sepsis.¹⁹⁰

190.

Reed and May, HealthGrades Patient Safety in American Hospitals Study, March 2011.

Airway Safety

Approximately 25,000 potentially life-threatening errors occur daily in hospital intensive care units (ICUs), and up to 10 percent of these adverse events involve unintended incidents in Airway Management; more than half of these errors have been deemed preventable.¹⁹¹

191.

Needham, D. M., Thompson, D. A., Holzmueller, C. G., Dorman, T., Lubomski, L. H., Wu, A. W., … & Pronovost, P. J. (2004). A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Critical Care Medicine, 32(11), 2227-2233.

Neonatal Safety

At least 300 infants with an unrecognized CCHD are discharged each year from newborn nurseries in the United States.¹⁹²

192.

Aamir T, Kruse L, Ezeakudo O. Delayed diagnosis of critical congenital cardiovascular malformations (CCVM) and pulse oximetry screening of newborns. Acta Paediatr. 2007;96:1146-1149

Neonatal Safety

Critical congenital heart disease is estimated to affect one out of every 48,000 babies born each year in the U.S.¹⁹³

193.

Babies First Test. Retrieved from: http://www.babysfirsttest.org/newborn-screening/conditions/critical-congenital-heart-disease-cchd

Neonatal Safety

Studies show that newborns treated with higher level of oxygen had more cognitive disabilities than those treated with lower oxygen.¹⁹⁴

194.

Sun SC. Relation of target SpO₂ levels and clinical outcome in ELBW infants on supplemental oxygen. Pediatr Res (2002) 51:A350.

Neonatal Safety

Prevention or minimization of harm through adherence to evidence-based practice guidelines is the best defense against patient harm and malpractice claims.¹⁹⁵

195.

Neonatal Safety

Birth-associated adverse outcomes result in 2-10% or approximately 80-400,000 cases annually, half of which are preventable.¹⁹⁶

196.

Neonatal Safety

30-40% of birth-associated adverse outcomes or “near misses” may be preventable through changes in patient, health care provider, and system factors.¹⁹⁷

197.

Hand-Off Communications

An estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.¹⁹⁸

198.

Clutter—Part, C. (2012). Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-Off Communications. Joint Commission Perspectives.

Anemia & Transfusions

Restrictive transfusion strategies can reduce the risk of receiving RBC transfusions by 39%, and are associated with reductions in hospital mortality.¹⁹⁹

199.

Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD002042.

Anemia & Transfusions

About 0.5% to 3% of all transfusions result in some adverse events.²⁰⁰

200.

Kumar, P., Thapliyal, R., Coshic, P., & Chatterjee, K. (2013). Retrospective evaluation of adverse transfusion reactions following blood product transfusion from a tertiary care hospital: A preliminary step towards hemovigilance. Asian Journal of Transfusion Science, 7(2), 109–115. http://doi.org/10.4103/0973-6247.115564

Anemia & Transfusions

With 15 million RBC units transfused per year, the estimated risk for death due to hemolysis is 1:1,250,000 or 8 per 10 million RBC units.²⁰¹

201.

Federowicz I, Barrett BB, Andersen JW, Urashima M, Popovsky MA, Anderson KC. Characterization of reactions after transfusion of cellular blood components that are white cell reduced before storage. Transfusion. 1996;36: 21-8. [PMID: 8607149].

Anemia & Transfusions

Transfusion-related fatalities due to hemolysis reported to the U.S. Food and Drug Administration averaged 12.5 deaths per year from 2005 to 2010.²⁰²

202.

Carson, J. L., Grossman, B., Kleinman, S., Tinmouth, A. T., Marques, M. M., Fung, M. K., … Djulbegovic, B. (2012). Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB. Annals of Internal Medicine. doi:10.7326/0003-4819-156-12-201206190-00429

Monitoring for Opioid-Induced Respiratory Depression

Failure to rescue accounts for 60,000 deaths each year in Medicare patients under age 75.²⁰³

203.

HealthGrades Quality Study. (2004, July). Patient safety in American hospitals. Retrieved from: http://www.providersedge.com/ehdocs/ehr_articles/Patient_Safety_in_American_Hospitals-2004.pdf

Monitoring for Opioid-Induced Respiratory Depression

Incidence rate of failure to rescue is 8-16.9%.²⁰⁴

204.

Johnston, M.J. et al. (2015, April). A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery, 157 (4), 752-763. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25794627

Monitoring for Opioid-Induced Respiratory Depression

The majority of failure to rescue cases on nursing unites are progressive; that education of the nursing staff along with the utilization of those monitoring tools is what is key to the success of being able to identify and immediately intervene before the patient begins to get into trouble.²⁰⁵

205.

Susan Lorenz, DrNP, RN, NEC-BEC, EDAC, Vice President of Patient Care Services and Chief Nursing Officer, Princeton HealthCare System.

Monitoring for Opioid-Induced Respiratory Depression

68% of all failure-to-rescue deaths occur among surgical inpatients with treatable complications, pressure ulcers, post-operative respiratory failure, and post-operative sepsis.²⁰⁶

206.

Reed and May, HealthGrades Patient Safety in American Hospitals Study, March 2011.

Medication Safety

There is 22% of those adverse drug events were preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively.²⁰⁷

207.

Joint Commission. (2008). Preventing pediatric medication errors. Sentinel Event Alert, 39, 1-4.

Medication Safety

There is an 11.1% of adverse drug events in pediatric patients.²⁰⁸

208.

Joint Commission. (2008). Preventing pediatric medication errors. Sentinel Event Alert, 39, 1-4.

Medication Safety

At least 56.7% of pediatric adverse drug events are preventable.²⁰⁹

209.

Kunac, D. L., Kennedy, J., Austin, N., & Reith, D. (2009). Incidence, Preventability, and Impact of Adverse Drug Events (ADEs) and Potential ADEs in Hospitalized Children in New Zealand. Pediatric Drugs, 11(2), 153-160. doi:10.2165/00148581-200911020-00005

Medication Safety

The most common types of harmful pediatric medication errors are: Improper dose/quantity (37.5%), omission error (19.9%), unauthorized/wrong drug (13.7%), prescribing error (9.4%), wrong administration technique, wrong time, drug prepared incorrectly, wrong dosage form, and wrong route.²¹⁰

210.

Joint Commission. (2008). Preventing pediatric medication errors. Sentinel Event Alert, 39, 1-4.

Medication Safety

Patients 80 years or older are 5 times more likely to be hospitalized for insulin-related hypoglycemia and errors than those 45 – 64 years of age.²¹¹

211.

Geller, A. I., Shehab, N., Lovegrove, M. C., Kegler, S. R., Weidenbach, K. N., Ryan, G. J., & Budnitz, D. S. (2014). National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA internal medicine, 174(5), 678-686.

Medication Safety

Prevalence of hypoglycemia (serum glucose <70 mg/dL) was reported as 5.7% of all point-of-care blood glucose (BG) tests in a 2009 survey of 575 hospitals.²¹²

212.

Swanson, C., Potter, D., Kongable, G., & Cook, C. (2011). Update on inpatient glycemic control in hospitals in the United States. Endocrine Practice.

Medication Safety

Implementation of anti-microbial stewardship is associated with 50% reduction in the odds of developing Clostridium difficile infection and 15.2% decrease in antimicrobial cost per patient-day.²¹³

213.

Malani, A. N., Richards, P. G., Kapila, S., Otto, M. H., Czerwinski, J., & Singal, B. (2013). Clinical and economic outcomes from a community hospital’s antimicrobial stewardship program. American Journal of Infection Control, 41(2), 145-148.

Medication Safety

An estimated two million people in the U.S. are infected with antibiotic-resistant organisms each year, leading to 23,000 deaths.²¹⁴

214.

Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013 Atlanta, GA: CDC;2013.

Medication Safety

23% of European Union (EU) citizens claim to have been directly affected by medical errors.²¹⁵

215.

World Health Organization. Data and statistics. Retrieved from: http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics

Medication Safety

20-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate.²¹⁶

216.

Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. Retrieved from: https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Medication Safety

Evidence on medical errors shows that 50% to 70.2% of such harm can be prevented through comprehensive systematic approaches to patient safety.²¹⁷

217.

World Health Organization. Data and statistics. Retrieved from: http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics

Medication Safety

No U.S. standard exists to quantify harm or death due to medical error.²¹⁸

218.

Donaldson, M. S., Corrigan, J. M., & Kohn, L. T. (Eds.). (2000). To err is human: Building a safer health system (Vol. 6). National Academies Press.

Medication Safety

Human error has been implicated in nearly 80% of adverse events that occur in complex healthcare systems.²¹⁹

219.

Palmieri, P. A.; DeLucia, P. R.; Ott, T. E.; Peterson, L. T.; Green, A. (2008). The anatomy and physiology of error in adverse healthcare events. Advances in Health Care Management. 7. pp. 33–68. doi:10.1016/S1474-8231(08)07003-1. ISBN 978-1-84663-954-8. ISSN 1474-8231.

Medication Safety

Medical errors are the third leading cause of death behind heart disease and cancer – more than car accidents, AIDS, and diabetes combined.^220,221

220.

Centers for Disease Control and Prevention. (2016, October 7). Leading Causes of Death. Retrieved from: https://www.cdc.gov/nchs/fastats/deaths.htm

221.

Centers for Disease Control and Prevention. (2016, December 2). HIV in the United States: At A Glance. Retrieved from: https://www.cdc.gov/hiv/statistics/overview/ataglance.html

Medication Safety

Research estimates over 200,000 deaths are attributed to medical errors each year in the United States.²²²

222.

Donaldson, M. S., Corrigan, J. M., & Kohn, L. T. (Eds.). (2000). To err is human: Building a safer health system (Vol. 6). National Academies Press.

Medication Safety

Approximately 90% of inpatient medication errors occur at either the ordering or transcribing stage.²²³

223.

Bates D.W., Cullen D.J., Laird N., Petersen L.A., Small S.D., Servi D., Laffel G., … Edmondson A. Incidence of Adverse Drug Events and Potential Adverse Drug Events Implications for Prevention. JAMA. 1995;274(1):29-34. doi:10.1001/jama.1995.03530010043033.

Medication Safety

Medication errors harm at least 1.5 million people every year.²²⁴

224.

Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually. (2006). The National Academics of Sciences, Engineering, Medicine. Retrieved June 08, 2017, from http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623

Healthcare-Associated Infections

There has been a 50% decrease in CLABSIs between 2008 and 2014.²²⁵

225.

Centers for Disease Control and Prevention. (2014). National and state healthcare associated infections progress report. Atlanta, GA: Centers for Disease Control and Prevention.

Healthcare-Associated Infections

CLABSIs result annually in: 84,551 to 203,916 preventable infections, 10,426 to 25,145 preventable deaths, and $1.7 to $21.4 billion avoidable costs²²⁶

226.

Agency for Health Research and Quality. Appendix 2. Central line-associated bloodstream infections fact sheet. (2014). Retrieved from http://www.ahrq.gov/professionals/education.curriculum-tools/clabsitools/clabsitoolsap2.html

Healthcare-Associated Infections

An estimated 250,000-500,000 CLABSIs occur in U.S. hospitals each year.²²⁷

227.

Medscape. Advances in Central Line Insertion and Care: Skin Antisepsis for Prevention and Control of Catheter-Related and Surgical Site Infections.

Healthcare-Associated Infections

Increased cost (the non-inflation-adjusted attributable cost) of CLABSIs have been found to vary from $3,700 to $39,000 per episode.²²⁸

228.

Marschall, J., Mermel, L., Fakih, M., Hadaway, L., Kallen, A., O’Grady, N., . . . Yokoe, D. (2014). Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology, 35(7), 753-771. doi:10.1086/676533.

Healthcare-Associated Infections

In the United States, approximately 250,000 CLABSIs are estimated to occur each year, associated with a death rate of 12-25% and extended hospital stays, at a cost of up to $56,000 per infection.²²⁹

229.

Centers for Disease Control and Prevention. (2011). Guidelines for the Prevention of Intravascular Catheter-Related Infections.

Healthcare-Associated Infections

29,000 people who were initially diagnosed with CDI died within 30 days.²³⁰

230.

Lessa, F. C., Mu, Y., Bamberg, W. M., Beldavs, Z. G., Dumyati, G. K., Dunn, J. R. … McDonald, L. C. (2015). Burden of Clostridium difficile Infection in the United States. The New England Journal of Medicine,372, 825-834. doi:10.1056/NEJMoa1408913.

Healthcare-Associated Infections

In 2011, CDI was estimated to cause almost half a million infections in the United States.²³¹

231.

Lessa, F. C., Mu, Y., Bamberg, W. M., Beldavs, Z. G., Dumyati, G. K., Dunn, J. R. … McDonald, L. C. (2015). Burden of Clostridium difficile Infection in the United States. The New England Journal of Medicine,372, 825-834. doi:10.1056/NEJMoa1408913.

Healthcare-Associated Infections

Clostridum difficile infection accounts for 15-25% of antibiotic-associated diarrhea.²³²

232.

DePestel, D. D., & Aronoff, D. M. (2013). Epidemiology of Clostridium difficile Infection. Journal of Pharmacy Practice, 26(5), 464–475. http://doi.org/10.1177/0897190013499521

Healthcare-Associated Infections

VAP increases patient time in the ICU by 4 to 6 days.²³³

233.

Halyard Health. Ventilator Associated Pneumonia. Retrieved from: http://www.halyardhealth.com/hai-watch/hai-threats-solutions/ventilator-associated-pneumonia.aspx

Healthcare-Associated Infections

VAP is the most common and deadly healthcare-associated infection, affecting up to 28% of ventilated patients.²³⁴

234.

Kalanuria, A. A., Zai, W., & Mirski, M. (2014). Ventilator-associated pneumonia in the ICU. Critical Care, 18(2), 208. http://doi.org/10.1186/cc13775

Healthcare-Associated Infections

Costs due to SSIs can reach up to $10 billion annually.²³⁵

235.

Perencevich, E. N., Sands, K. E., Cosgrove, S. E., Guadagnoli, E., Meara, E., & Platt, R. (2003). Health and Economic Impact of Surgical Site Infections Diagnosed after Hospital Discharge. Emerging Infectious Diseases, 9(2), 196–203. http://doi.org/10.3201/eid0902.020232

Healthcare-Associated Infections

Length of hospital stay can result in 7-10 additional postoperative hospital days due to an SSI.²³⁶

236.

Kaye, K. S., Anderson, D. J., Sloane, R., Chen, L. F., Choi, Y., Link, K., … Schmader, K. E. (2009). The Impact of Surgical Site Infection on Older Operative Patients. Journal of the American Geriatrics Society, 57(1), 46–54. http://doi.org/10.1111/j.1532-5415.2008.02053.x

Healthcare-Associated Infections

Continuous monitoring in post-surgical patients was shown to reduce ICU transfers by 48% and rapid response activations by 65% – with no deaths or brain damage over a five year period.²³⁷

237.

Through Movement (Rep.). (2017). Retrieved http://www.masimo.com/globalassets/image/homepage/masimo_annual_report_2016_international.pdf

Healthcare-Associated Infections

Surgical site infections occur in 2-5% of patients undergoing inpatient surgery.²³⁸

238.

Anderson, D. J., Podgorny, K., Berríos-Torres, S. I., Bratzler, D. W., Dellinger, E. P., Greene, L., … & Kaye, K. S. (2014). Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(06), 605-627.

Healthcare-Associated Infections

Urinary tract infections (UTIs) are the most common nosocomial infection, accounting for up to 40% of infections reported by acute care hospitals.²³⁹

239.

Saint, S., Kowalski, C. P., Kaufman, S. R., Hofer, T. P., Kauffman, C. A., Olmsted, R. N., … & Krein, S. L. (2008). Preventing hospital-acquired urinary tract infection in the United States: a national study. Clinical Infectious Diseases, 46(2), 243-250.

Healthcare-Associated Infections

There are an estimated 13,000 deaths annually attributable to CAUTIs.²⁴⁰

240.

Gould, C. (2010). Catheter-associated urinary tract infection (CAUTI) toolkit. Centers for Disease Control and Prevention, Atlanta, Georgia.

Hand Hygiene

Patients hospitalized for MRSA have longer hospital stays and are more likely to die than patients who do not have MRSA.²⁴¹

241.

Agency for Healthcare Research and Quality (AHRQ). (2011). Healthcare-Associated Infections. Retrieved from www.ahrq.gov/qual/hais.htm.

Hand Hygiene

Several studies have demonstrated that handwashing virtually eradicates the carriage of MRSA which invariably occurs on the hands of Health Care Practitioners working in ICUs.²⁴²

242.

Mathur, P. (2011). Hand hygiene: Back to the basics of infection control. The Indian Journal of Medical Research, 134(5), 611–620. http://doi.org/10.4103/0971-5916.90985.

Hand Hygiene

Proper hand hygiene is the single most important, simplest, and least expensive means of reducing the prevalence of HAIs and the spread of antimicrobial resistance.²⁴³

243.

Mathur, P. (2011). Hand hygiene: Back to the basics of infection control. The Indian Journal of Medical Research, 134(5), 611–620. http://doi.org/10.4103/0971-5916.90985

Healthcare-Associated Infections

HAIs declined 17% from 2010 to 2013.²⁴⁴

244.

Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms. Content last reviewed November 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2013.html

Healthcare-Associated Infections

Infections associated with health care affect an estimated 1 in 20 hospital patients on average every year (estimated at 4.1 million patients).²⁴⁵

245.

World Health Organization. Data and statistics. Retrieved from: http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics

Healthcare-Associated Infections

1 out of every 25 hospitalized patients in the U.S. contracts an HAI during their stay.²⁴⁶

246.

Healthcare-associated Infections. (2016). Retrieved June 08, 2017, from https://www.cdc.gov/hai/surveillance/

Healthcare-Associated Infections

Approximately 1 to 3 out of every 100 patients who have surgery develop infections.²⁴⁷

247.

Center for Disease Control and Prevention. (2010). Healthcare-associated Infections. Retrieved from https://www.cdc.gov/hai/ssi/faq_ssi.html

Healthcare-Associated Infections

HAIs cost hospitals approximately $9.8 billion every year.²⁴⁸

248.

Gregory, A., Chami, E., & Pietsch, J. (2016). Emotional motivators: Using visual triggers as an infection control intervention to increase hand hygiene compliance throughout the hospital. American Journal of Infection Control, 44(6), S3.

Healthcare-Associated Infections

More than 700,000 HAIs occur annually in the United States.²⁴⁹

249.

Center for Disease Control and Prevention. (n.d.). Preventing Healthcare-Associated Infections. Retrieved https://www.cdc.gov/washington/~cdcatWork/pdf/infections.pdf

Healthcare-Associated Infections

An estimated 1.7 million healthcare-associated infections occur each year leading to 99,000 deaths.²⁵⁰

250.

Center for Disease Control and Prevention. (n.d.). Preventing Healthcare-Associated Infections. Retrieved https://www.cdc.gov/washington/~cdcatWork/pdf/infections.pdf

Creating a Foundation for Safe and Reliable Care

“Leadership matters, and so, I think you have to have board and executive leadership that cares as much about clinical outcomes, as financial outcomes.”²⁵¹

251.

Steven C. Moreau, President and Chief Executive Officer, St. Joseph Hospital

Creating a Foundation for Safe and Reliable Care

Limited health literacy skills are associated with an increase in preventable hospital visits and admissions.²⁵²

252.

Baker DW, Parker RM, Williams MV, Clark WS. 1997. The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health. 87(6): 1027-1030.

Creating a Foundation for Safe and Reliable Care

Hospital departments where staff have more positive patient safety culture perceptions have less adverse events.²⁵³

253.

Najjar, S., Nafouri, N., Vanhaecht, K., & Euwema, M. (2015). The relationship between patient safety culture and adverse events: A study in Palestinian hospitals. Safety in Health, 1(1), 1.

*General Patient Safety Statistics

Public health education and advocacy initiatives, such as anti-tobacco and cancer awareness campaigns, totaled an estimated $77.9 billion in 2013, less than 3% of total health spending.²⁵⁴

254.

Dieleman, J. L., Baral, R., Birger, M., Bui, A. L., Bulchis, A., Chapin, A., … & Lavado, R. (2016). US spending on personal health care and public health, 1996-2013. JAMA, 316(24), 2627-2646.

*General Patient Safety Statistics

By 2020, non-communicable diseases are expected to account for 7 out of 10 deaths in developing regions.²⁵⁵

255.

Boutayeb, A., & Boutayeb, S. (2005). The burden of non communicable diseases in developing countries. International Journal for Equity in Health, 4(1), 1.

*General Patient Safety Statistics

Unsafe surgery is the third leading cause of death globally.²⁵⁶

256.

Nadmin, P. O. (2015, June 22). Unsafe surgery and anaesethesia lead to third of all deaths. Retrieved December 22, 2016, from http://www.opnews.com/2015/06/safe-surgery-anaesethesia-third-deaths/11529

*General Patient Safety Statistics

2010 research claims that 17 million people die per year due to lack of access to affordable safety surgery.²⁵⁷

257.

Millions dying due to lack of access to affordable and safe surgery: report. (2015, April 26). Retrieved December 22, 2016, from http://www.abc.net.au/worldtoday/content/2015/s4224506.htm

*General Patient Safety Statistics

The United States spends more on health care annually than any other country yet ranks only 36th in the world for life expectancy.²⁵⁸

258.

World Health Organization. (2000). WORLD HEALTH ORGANIZATION ASSESSES THE WORLD’S HEALTH SYSTEMS.(cited 2010 June 8).

*General Patient Safety Statistics

Did you know? No U.S. standard exists to quantify harm or death due to medical error.²⁵⁹

259.

Donaldson, M. S., Corrigan, J. M., & Kohn, L. T. (Eds.). (2000). To err is human: Building a safer health system(Vol. 6). National Academies Press.

*General Patient Safety Statistics

Human error has been implicated in nearly 80% of adverse events that occur in complex healthcare systems.²⁶⁰

260.

Palmieri, P. A.; DeLucia, P. R.; Ott, T. E.; Peterson, L. T.; Green, A. (2008). The anatomy and physiology of error in averse healthcare events. Advances in Health Care Management. 7. pp. 33–68. doi:10.1016/S1474-8231(08)07003-1. ISBN 978-1-84663-954-8. ISSN 1474-8231

*General Patient Safety Statistics

Medical errors are the THIRD leading cause of death behind heart disease and cancer – More than car accidents, AIDS & diabetes combined.^261,262

261.

Centers for Disease Control and Prevention. (2016, October 7). Leading Causes of Death. Retrieved from: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

262.

Centers for Disease Control and Prevention. (2016, December 2). HIV in the United States: At A Glance. Retrieved from:
https://www.cdc.gov/hiv/statistics/overview/ataglance.html

*General Patient Safety Statistics

Research estimates over 200,000 deaths are attributed to medical errors each year in the United States.²⁶³

263.

Donaldson, M. S., Corrigan, J. M., & Kohn, L. T. (Eds.). (2000). To err is human: Building a safer health system (Vol. 6). National Academies Press.

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