Appendix B (Continued)

Cost of Poor Quality or Waste in Integrated Delivery System Settings

Table 3: Total Incremental Cost and Patient Days Associated with Voluntary Event Reports

Event TypeCost per EventNumber of EventsTotal CostDays per EventTotal Days
Medication$9134543$4,149,3460.522364
Treatment$5014622$2,316,7020.25701
Fall$8971025$919,5070.681162
Equipment$489635$310,8080.25124
Behavioral$659569$375,1260.20238
Loss/Exposure$552542$299,4480.42265
Overall$74911936$8,370,9370.434854

Notes: Total cost and days for each event report type of is calculated by multiplying the type-specific per event estimate by the number events of that type. The total cost and days reported above is the sum of the type-specific total cost and days to reflect the frequency of each event type. The overall cost and days per event estimate reported above in italics is from the initial regressions that did not contain type dummy variables and is not used in the calculation of total cost and days.

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Table 4: Distribution of Medication Event Subtypes

Medication SubtypePercent of Medication EventsPercent with No Harm
Omission30%95%
Other14%86%
Wrong Dose11%95%
Wrong Time9%99%
Wrong Drug7%97%
Infiltration/Phlebitis6%35%
Incomplete Documentation6%98%
Wrong Rate5%94%
Wrong Patient3%99%
Narcotic Count Related2%99%
Wrong Solution2%96%
Wrong Route2%93%
Wasted Blood/Blood Products1%91%
Wrong Preparation1%90%
Adverse Reaction1%49%
Contra Indication1%91%

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Table 5: Distribution of Fall Event Subtypes

Fall SubtypePercent of Fall EventsPercent with No Harm
From Bed35%82%
From Walk/Stand34%81%
From Commode/Toilet10%78%
From Chair/Stool8%89%
Other6%75%
Visitor Fall3%79%
In Hallway1%82%
From Wheelchair1%100%
From Table/Stretcher1%57%
From Shower/Tub0%80%

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Table 6: Distribution of Treatment Event Subtypes

Treatment SubtypePercent of Treatment EventsPercent with No Harm
Delayed27%94%
Omitted26%94%
Incorrect15%92%
Other14%90%
Procedural Complication3%52%
Wrong Patient3%89%
Count Discrepancy3%99%
Skin Issue2%51%
H&P Issue1%100%
Contamination1%92%
Unattended Delivery1%95%
Wrong Time1%96%
Injury0%65%
Test Discrepancy0%100%
Unexpected Death0%50%
Latex Sensitivity0%83%
Wrong Site0%100%

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Table 7: Distribution of Equipment Event Subtypes

Equipment SubtypePercent of Equipment EventsPercent with No Harm
Malfunction49%91%
Other19%89%
Not Available16%88%
SMDA Related8%86%
Incorrect6%97%
Improper Disposal3%95%

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Table 8: Distribution of Behavioral Event Subtypes

Behavioral SubtypePercent of Behavioral EventsPercent with No Harm
Complaint35%91%
Other26%94%
Verbal Abuse9%98%
Physical Abuse/Threat8%77%
Unable to Contact Physician6%97%
Elopement4%100%
Self Inflicted Injury4%50%
AMA4%100%
Suicide Attempt2%73%
Legal Action/Threat of Action1%100%
Trespassing1%100%
Contraband1%100%
Illegal Drugs/Weapons0%100%
Sexual Abuse0%100%

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Table 9: Distribution of Loss Event Subtypes

Loss SubtypePercent of Loss EventsPercent with No Harm
Lost/Damaged/Stolen41%98%
Other35%92%
Exposure13%90%
Environmental10%96%
Signage Not Used0%100%

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Current as of September 2008
Internet Citation: Appendix B (Continued): Cost of Poor Quality or Waste in Integrated Delivery System Settings. September 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/costpqids/cpqidsappb1.html