Nearly 1,500 adverse events reported to the state last year

Kate Lauren
Katherine Fillo (left) and Lauren Nelson (right), Department of Public Health

The latest count of serious adverse events reported to the Massachusetts Department of Public Health indicates there is plenty of room for improving the safety of hospital and surgical care across the Commonwealth but pointed to several notable bright spots as well.

Serious Reportable Events (SREs) reported to the state by hospitals and ambulatory surgery centers (ASCs) in 2015 totaled 1,494, up from 1,067 in 2014 and 1,097 in 2013. Infection control lapses at a single hospital accounted for an unusually large number – 444 – of the SREs last year. 

The overall numbers of SREs, however, do not necessarily provide a good guide to year-to-year changes in patient safety (see “Explainer: What do the adverse event report data tell us?”).

“The SREs are just one measure out of many of patient safety,” says Katherine Fillo, RN-BC, MPH, MA, quality improvement manager for DPH's Bureau of Health Care Safety and Quality. “Beyond the numbers, each individual SRE includes a narrative of what caused the incident and how the hospital addressed it. So a lot of the value is in the qualitative analysis of each event.”

Fillo presented the latest SRE data at a meeting of the Public Health Council on Tuesday in Boston, along with an update on certain healthcare-associated infections.

Fillo says the quality of reporting for the SREs continued to improve last year. “There are probably some events still not being reported, but the challenge is mainly at the frontline provider level. If frontline personnel recognize an SRE, the institutions are good about reporting it.”

Vital safety data

The Betsy Lehman Center just released a new online tool this month to help healthcare personnel recognize and report SREs and other safety events (see “Introducing the Navigator”).The goal is to increase both the quality and volume of reports in order to better understand and prioritize key risks to patients’ safety. 

Paul Karner, the Center’s director of research and analysis, says the Center views the SREs as ‘signal data’ that can flag important trends in specific safety areas. “You have to dig into individual categories or even facilities to find out where the signal is borne out in reality,” Karner says.

A look at the 2015 SREs by category shows roughly the same pattern as in recent years, with falls and pressure ulcers—once called bed sores—making up almost two-thirds of all events, excluding the aforementioned 444 reports that stemmed from infection control lapses in a dialysis unit at Baystate Medical Center (see story in our June issue).

Sre Acute Vs Non Acute Chart Final

Collectively, hospitals reported 442 patient falls that resulted in serious injury or death last year, as well as 286 serious pressure ulcers.

Surgery-related errors accounted for 80 of the SREs. Thirty-six patients sustained serious burns from a number of sources, ranging from spilled hot coffee to misplaced surgical cauterization instruments. Reported suicides and other cases of serious self-harm accounted for 45 SREs last year, while assault reports totaled 30 (mostly by patients on staff at psychiatric units).

One possible bright spot in the data had to do with neonatal health. The number of babies who died or suffered serious injury during low-risk pregnancies fell from 27 in 2014 (and 22 the year before that) to just 15 in 2015.

Asked what categories of patient harm troubled her the most, Fillo pointed to the most frequent ones—like pressure ulcers and falls—that remain stubbornly high each year. “We don’t want people to start viewing those as ‘normal’ accidents, meaning just an inevitable part of care," she says.

National benchmarks

The number of advanced pressure ulcers and serious injuries from falls reported to the state have, in fact, been fairly consistent over the last three years. But a closer look at the data, by organization, shows marked improvement at some institutions.

At Boston Medical Center, for example, a concerted focus on nursing quality overall helped cut the number of serious pressure ulcers from 25 and 30 in 2013 and 2014 respectively, to only 11 last year.

Diane Hanley, senior director and associate chief nursing officer for professional practice, nursing quality and education, says the hospital participates in a national database that benchmarks its performance on pressure ulcers and other nursing quality indicators against some 2,000 other hospitals. Data are turned into graphs posted on ‘quality boards’ in every unit where nurses, patients and families can see them.

That encourages nurses to work to outperform not only national norms but also the unit down the hall. “It’s a healthy competition that results in the sharing of best practices,” Hanley says, “and part of our commitment to better patient care.”

Brigham and Women’s Hospital, meanwhile, logged a sharp reduction in the number of serious patient falls, with just 12 reported by the hospital last year. That compares with 19 in 2014 and 23 in 2013.

When patients arrive at the Brigham, says Escel Stanghellini, a quality program director who oversees the Fall Prevention and Restraint Management Programs, nurses assess their risk of falling and the likelihood that a fall will cause serious injury. Then they work with patients and families to develop a custom fall-prevention plan. The plan is shared with other care providers during hand off reports, rounds, and posted prominently in the patient’s room.

'Critical patient risks'

For patients who need extra attention, nurses can also add a portable bedside camera so a specially trained nurse’s aide can more closely monitor up to 10 patients at a time. “If a patient is trying to get out of bed without help or appears anxious, the aide can speak to the patient through the system speakers. The aides are also able to activate a stat alarm in the unit if the patient is observed doing something dangerous,” Stanghellini says. “This has prevented falls, saved a patient from choking, and allowed for earlier detection of changes in patients’ behavior.”

These safety monitors were first used as part of a pilot program a year and a half ago. It is now being used in all intermediate care units and will be rolled out in the critical care units throughout the hospital by the end of September, according to Stanghellini.

Examples like Boston Medical Center and the Brigham show that patient safety can improve when institutions make it a priority, says Barbara Fain, executive director of the Betsy Lehman Center. But they also underscore the need for more intensive efforts to combat preventable error in the many categories of SREs where the numbers indicate little progress.

“The power of this data is that it can shine a light on critical patient risks that probably exist in many hospitals and ASCs—not just at the facilities that reported the events,” Fain says. “True progress depends on a renewed commitment in every Massachusetts health care setting to create a culture of safety to support known strategies for preventing medical harm. That’s the challenge.”

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