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.

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

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

4 in 10 children suffer medication errors during an emergency.1
1.

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

1.3 million people injured from adverse drug events in 2017 alone2
2.

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

“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%).”3
3.

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

“The number of prescription drug shortages in the country nearly tripled between 2005 and 2010.”4
4.

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

“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.”5
5.

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

“Delirium is associated with multiple serious outcomes including increased morbidity, length of hospital stay, healthcare costs, institutionalization, and mortality”6
6.

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.

“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”7
7.

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

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.8
8.

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

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.9
9.

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 for anxiety and depression is one of the most well-evaluated interventions in mental health in primary care.10
10.

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 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.11
11.

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.

Recent mortality rates due to arterial emboli range from 4 to 15%.12
12.

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

Aortic atherosclerotic plaque is one of the leading sources of embolic disease.13
13.

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

Complications of arterial embolism are a leading cause of disability and death in the United States.14
14.

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

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.15
15.

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

The cost for each occurrence is an average of $66,007 per air embolism.16
16.

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

The mortality rate of central line related air emboli death ranges from 23% to 50%.17
17.

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

The incidence of massive air embolism in cardiac bypass procedures is between 0.003% and 0.007% with 50% having adverse outcomes.18
18.

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

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.19
19.

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

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.20
20.

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

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.21
21.

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

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.22
22.

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

Each year an estimated 646, 000 individuals die from falls globally. Of which over 80% are in low and middle-income countries.23
23.

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

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 2013.24
24.

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

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.25
25.

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

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.26
26.

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)

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.27
27.

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

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.28
28.

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

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.29
29.

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).

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.30
30.

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

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.31
31.

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

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).32
32.

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

Between 2005 and 2011 the NPSA was notified of 21 deaths and 79 cases of harm due to misplaced NG tubes.33
33.

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

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.34
34.

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

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.35
35.

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

A 2015 study showed that 45% of adults are at risk for limited health literacy. That is nearly half of patients.36
36.

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

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.37
37.

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

A recent poll showed just under 60 percent of folks, even in higher age brackets, are willing to engage electronically with care providers.38
38.

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

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.39
39.

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.

Nearly 20% of the hospital beds for the nation’s most severely ill and dangerous psychiatric patients were eliminated in the last 5 years.40
40.

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.

Adults living with serious mental illness die on average 25 years earlier than other Americans, largely due to treatable medical conditions.41
41.

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

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 44.42
42.

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.

Serious mental illness costs America $193.2 billion in lost earning per year.43
43.

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

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.44
44.

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

Approximately 20% of youth ages 13 to 18 experience severe mental disorders in a given year.45
45.

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

25% of Americans experience mental illness in a given year.46
46.

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

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 2005.47
47.

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.

In Europe, there are 544,000 VTE-related deaths every year.48
48.

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

In the United States, there are 100,000 – 300,000 VTE-related deaths every year.49
49.

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

Every year, there are approximately 10 million cases of VTE worldwide.50
50.

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.

In the U.S. and Europe, VTE-related events kill more people than AIDS, breast cancer, prostate cancer and motor vehicle crashes combined.51
51.

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

11.1% of pregnancy-related deaths in the U.S. resulted from “hypertensive disorders of pregnancy,” including preeclampsia.52
52.

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

Pre-eclampsia is the cause of 15% of premature births in the U.S.53
53.

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 hemorrhage and pre-eclampsia account for over 70% of cases of severe maternal morbidity.54
54.

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

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.55
55.

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.

125,000 women a year are affected by postpartum hemorrhage.56
56.

The AWHONN Postpartum Hemorrhage Project. Maternal Morbidity & Mortality.

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.57
57.

The AWHONN Postpartum Hemorrhage Project. Maternal Morbidity & Mortality.

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.58
58.

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

Anemia is estimated to be responsible for 17-46% of cases in maternal death.59
59.

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

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.60
60.

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 hemorrhage and preeclampsia account for over 70% of cases of severe maternal morbidity.61
61.

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

The United States is the one of the only countries where maternal deaths and injuries have increased.62
62.

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

Every 10 minutes, a woman in the United States almost dies of pregnancy-related complications.63
63.

The AWHONN Postpartum Hemorrhage Project. Maternal Morbidity & Mortality.

30-40% of “near misses” and severe maternal morbidities may be preventable through changes in patient, health care provider, and system factors.64
64.

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

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.65
65.

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 was the most expensive condition treated in U.S. hospitals, costing more than $20 billion in 2011.66
66.

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

Sepsis is the number one cause of death in the ICU in the U.S.67
67.

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 mortality rate is 30-40%.68
68.

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

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 2011.69
69.

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.

Severe sepsis is a growing problem in the United States with estimates of up to 3,000,000 hospitalizations per year.70
70.

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.

At least 10 to 15% of sepsis deaths are avoidable by vaccination, hygienic measures, early detection, and prompt treatment measures.71
71.

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

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.72
72.

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

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.73
73.

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.

The incidence of perioperative complications is greater in patients with obstructive sleep apnea (OSA).74
74.

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

Sentinel events from respiratory depression are caused by wrong dosing 47% of the time and improper monitoring 29% of the time.75
75.

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

68% of all failure-to-rescue deaths occur among surgical inpatients with treatable complications, pressure ulcers, post-operative respiratory failure, and post-operative sepsis.76
76.

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

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.77
77.

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.

At least 300 infants with an unrecognized CCHD are discharged each year from newborn nurseries in the United States.78
78.

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

Critical congenital heart disease is estimated to affect one out of every 48,000 babies born each year in the U.S.79
79.

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

Studies show that newborns treated with higher level of oxygen had more cognitive disabilities than those treated with lower oxygen.80
80.

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

Prevention or minimization of harm through adherence to evidence-based practice guidelines is the best defense against patient harm and malpractice claims.81
81.

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

Birth-associated adverse outcomes result in 2-10% or approximately 80-400,000 cases annually, half of which are preventable.82
82.

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

30-40% of birth-associated adverse outcomes or “near misses” may be preventable through changes in patient, health care provider, and system factors.83
83.

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

An estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.84
84.

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

Restrictive transfusion strategies can reduce the risk of receiving RBC transfusions by 39%, and are associated with reductions in hospital mortality.85
85.

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.

About 0.5% to 3% of all transfusions result in some adverse events.86
86.

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

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.87
87.

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].

Transfusion-related fatalities due to hemolysis reported to the U.S. Food and Drug Administration averaged 12.5 deaths per year from 2005 to 2010.88
88.

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

Failure to rescue accounts for 60,000 deaths each year in Medicare patients under age 75.89
89.

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

Incidence rate of failure to rescue is 8-16.9%.90
90.

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

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.91
91.

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

68% of all failure-to-rescue deaths occur among surgical inpatients with treatable complications, pressure ulcers, post-operative respiratory failure, and post-operative sepsis.92
92.

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

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.93
93.

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

There is an 11.1% of adverse drug events in pediatric patients.94
94.

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

At least 56.7% of pediatric adverse drug events are preventable.95
95.

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

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.96
96.

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

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.97
97.

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.

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.98
98.

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

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.99
99.

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.

An estimated two million people in the U.S. are infected with antibiotic-resistant organisms each year, leading to 23,000 deaths.100
100.

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

23% of European Union (EU) citizens claim to have been directly affected by medical errors.101
101.

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

20-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate.102
102.

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

Evidence on medical errors shows that 50% to 70.2% of such harm can be prevented through comprehensive systematic approaches to patient safety.103
103.

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

No U.S. standard exists to quantify harm or death due to medical error.104
104.

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.

Human error has been implicated in nearly 80% of adverse events that occur in complex healthcare systems.105
105.

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.

Medical errors are the third leading cause of death behind heart disease and cancer – more than car accidents, AIDS, and diabetes combined.106,107
106.

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

107.

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

Research estimates over 200,000 deaths are attributed to medical errors each year in the United States.108
108.

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.

Approximately 90% of inpatient medication errors occur at either the ordering or transcribing stage.109
109.

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 errors harm at least 1.5 million people every year.110
110.

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

There has been a 50% decrease in CLABSIs between 2008 and 2014.111
111.

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

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 costs112
112.

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

An estimated 250,000-500,000 CLABSIs occur in U.S. hospitals each year.113
113.

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

Increased cost (the non-inflation-adjusted attributable cost) of CLABSIs have been found to vary from $3,700 to $39,000 per episode.114
114.

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.

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.115
115.

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

29,000 people who were initially diagnosed with CDI died within 30 days.116
116.

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.

In 2011, CDI was estimated to cause almost half a million infections in the United States.117
117.

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.

Clostridum difficile infection accounts for 15-25% of antibiotic-associated diarrhea.118
118.

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

VAP increases patient time in the ICU by 4 to 6 days.119
119.

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

VAP is the most common and deadly healthcare-associated infection, affecting up to 28% of ventilated patients.120
120.

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

Costs due to SSIs can reach up to $10 billion annually.121
121.

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

Length of hospital stay can result in 7-10 additional postoperative hospital days due to an SSI.122
122.

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

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.123
123.

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

Surgical site infections occur in 2-5% of patients undergoing inpatient surgery.124
124.

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.

Urinary tract infections (UTIs) are the most common nosocomial infection, accounting for up to 40% of infections reported by acute care hospitals.125
125.

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.

There are an estimated 13,000 deaths annually attributable to CAUTIs.126
126.

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

Patients hospitalized for MRSA have longer hospital stays and are more likely to die than patients who do not have MRSA.127
127.

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

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.128
128.

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.

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.129
129.

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

HAIs declined 17% from 2010 to 2013.130
130.

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

Infections associated with health care affect an estimated 1 in 20 hospital patients on average every year (estimated at 4.1 million patients).131
131.

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

1 out of every 25 hospitalized patients in the U.S. contracts an HAI during their stay.132
132.

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

Approximately 1 to 3 out of every 100 patients who have surgery develop infections.133
133.

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

HAIs cost hospitals approximately $9.8 billion every year.134
134.

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.

More than 700,000 HAIs occur annually in the United States.135
135.

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

An estimated 1.7 million healthcare-associated infections occur each year leading to 99,000 deaths.136
136.

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

“Leadership matters, and so, I think you have to have board and executive leadership that cares as much about clinical outcomes, as financial outcomes.”137
137.

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

Limited health literacy skills are associated with an increase in preventable hospital visits and admissions.138
138.

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.

Hospital departments where staff have more positive patient safety culture perceptions have less adverse events.139
139.

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.

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.140
140.

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.

By 2020, non-communicable diseases are expected to account for 7 out of 10 deaths in developing regions.141
141.

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

Unsafe surgery is the third leading cause of death globally.142
142.

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

2010 research claims that 17 million people die per year due to lack of access to affordable safety surgery.143
143.

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

The United States spends more on health care annually than any other country yet ranks only 36th in the world for life expectancy.144
144.

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

Did you know? No U.S. standard exists to quantify harm or death due to medical error.145
145.

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.

Human error has been implicated in nearly 80% of adverse events that occur in complex healthcare systems.146
146.

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

Medical errors are the THIRD leading cause of death behind heart disease and cancer – More than car accidents, AIDS & diabetes combined.147,148
147.

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

148.

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

Research estimates over 200,000 deaths are attributed to medical errors each year in the United States.149
149.

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.