2012 National Healthcare Disparities Report

Chapter 3. Patient Safety

Importance

Mortality
Number of Americans who die each year from medical errors (1999 est.)44,000-98,000 (Kohn, et al., 2000)
Prevalence
Rate of selected hospital-acquired conditions (2010 est.)145 per 1,000 hospital admissions (HHS, 2012)
Adverse drug reactions during hospital admissions (annual est.)49 per 1,000 hospital admissionsi
Rate of adverse drug events among Medicare beneficiaries in ambulatory settings50 per 1,000 person-years (Gurwitz, et al., 2003)
Cost
Cost attributable to medical errors (2008)$19.5 billion (Shreve, et al., 2010)
Total cost per error (2008)$13,000 (Shreve, et al., 2010)
Annual cost attributable to surgical errors (2008)$1.5 billion (Encinosa & Hellinger, 2008)

Measures

The Institute of Medicine (IOM) defines patient safety as "freedom from accidental injury due to medical care or medical errors" (Kohn, et al., 2000). In 1999, the IOM published To Err Is Human: Building a Safer Health System, which called for a national effort to reduce medical errors and improve patient safety (Kohn, et al., 2000).

In response to the IOM's report, President George W. Bush signed the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act).ii The act was designed to spur the development of voluntary, provider-driven initiatives to improve the quality, safety, and outcomes of patient care. The Patient Safety Act addresses many of the current barriers to improving patient care.

Central to this effort is the ability to measure and track adverse events. Measuring patient safety is complicated by difficulties in assessing and ensuring the systematic reporting of medical errors and adverse events. All too often, adverse event reporting systems are laborious and cumbersome. Health care providers may also fear that if they participate in the analysis of medical errors or patient care processes, the findings may be used against them in court or harm their professional reputations. In addition, many factors limit the ability to aggregate data in sufficient numbers to rapidly identify prevalent risks and hazards in the delivery of patient care, their underlying causes, and practices that are most effective in mitigating them. These include difficulties aggregating and sharing data confidentially across facilities or State lines.

To Err Is Human does not mention race or ethnicity when discussing the problem of patient safety, and data are limited. Any differences that suggest patient race or ethnicity might influence the risk of experiencing a patient safety event must be investigated to better understand the underlying reasons for any differences before the differences can be eliminated.

Despite these limitations, a more complete picture of patient safety is emerging. In recent years, progress has been made in raising awareness, developing reporting systems, and establishing national data collection standards. Examining patient safety using a combination of administrative data, medical record abstraction, spontaneous adverse event reports, and patient surveys allows a more robust understanding of what is improving and what is not. Still, data remain incomplete for a comprehensive national assessment of patient safety (Aspden, et al., 2004).

To increase access to high-quality, affordable health care for all Americans, one of the broad aims of the National Quality Strategy (NQS) is providing better care. One way to advance this aim is by focusing on the priority of making care safer by reducing harm caused during the delivery of care. This priority has great potential for rapidly improving health outcomes and increasing the effectiveness of care for all populations. The NQS states that health care providers should aim to reduce the rates of care-related injury to zero whenever possible and should strive to create a system that reliably provides high-quality health care for everyone.

The Department of Health and Human Services (HHS) created the Partnership for Patients to improve the quality, safety, and affordability of health care for all Americans. One of the goals of this partnership is to:

  • Keep patients from getting injured or sicker.
    • By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared with 2010. Achieving this goal would mean approximately 1.8 million fewer injuries to patients, with more than 60,000 lives saved over 3 years.

Achieving the partnership's goals will save lives and prevent injuries to millions of Americans. In addition, up to $35 billion could be saved across the health care system, including up to $10 billion in Medicare savings over a period of 3 years. Over a period of 10 years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings. This will help put our Nation on the path toward a more sustainable health care system.

The National Healthcare Disparities Report (NHDR) has tracked a growing number of patient safety measures. Organized around the Partnership for Patients' priority of safety, the 2012 NHDR presents the following measures that relate to the goal to keep patients from getting injured or sicker:

  • Healthcare-associated infections (HAIs):
    • Postoperative sepsis.
    • Catheter-associated urinary tract infections (UTIs).
    • Central line-associated bloodstream infections (CLABSIs).
  • Adverse events:
    • Mechanical adverse events associated with central venous catheters.
    • Obstetric trauma.
  • Patient safety culture:
    • Results from the 2011 Hospital Survey on Patient Safety Culture.

Two measures related to HAIs have reached the 95% threshold and have therefore been retired:

  • Appropriate care among surgical patients.
  • Appropriate timing of antibiotics among surgical patients.

Findings

Healthcare-Associated Infections

Infections acquired during hospital care (nosocomial infections) are one of the most serious patient safety concerns. They are the most common complication of hospital care (Gastmeier, 2004). An estimated 1.7 million HAIs occur each year in hospitals, leading to about 100,000 deaths. The most common infections are urinary tract, surgical site, and bloodstream infections (Klevens, et al., 2007).

A specific medical error cannot be identified in most cases of HAIs. However, better application of evidence-based preventive measures can reduce HAI rates within an institution.

Outcome: Postoperative Sepsis

Sepsis, a severe bloodstream infection, can occur after surgery. In a recent study, postoperative sepsis occurred in 5% of emergency surgery patients and 2% of elective surgery patients (Moore, et al., 2010). Another study revealed that higher rates of infection and higher risk of acute organ dysfunction both contribute to higher sepsis rates among Blacks compared with Whites (Mayr, et al., 2010). One way to reduce sepsis rates is by giving patients appropriate prophylactic antibiotics 1 hour prior to surgical incision.

  Figure 3.1. Postoperative sepsis per 1,000 adult elective-surgery discharges with an operating room procedure, by race/ethnicity and insurance, 2008-2009

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Key: API = Asian and Pacific Islander.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, State Inpatient Databases disparities analysis file, and AHRQ Quality Indicators, modified version 4.1.
Denominator: All elective hospital surgical discharges, age 18 and over, with length of stay of 4 or more days, excluding patients admitted for infection, patients with cancer or immunocompromised states, patients with obstetric conditions, and admissions specifically for sepsis.
Note: For this measure, lower rates are better. White, Black, and API are non-Hispanic. Hispanic includes all races. Rates are adjusted by age, gender, age-gender interactions, comorbidities, and diagnosis-related group clusters.

  • In 2009, Whites had a significantly lower rate of postoperative sepsis than Blacks, APIs, and Hispanics (15.6 per 1,000 hospital discharges compared with 18.9, 19, and 17.7, respectively; Figure 3.1).
  • In 2009, surgery patients with Medicaid had significantly higher rates of postoperative sepsis than surgery patients with private insurance (18.7 per 1,000 hospital discharges compared with 14.1).

Also, in the NHQR:

  • In 2009, surgery patients ages 18-44 had significantly lower rates of postoperative sepsis than those ages 45-64 and those age 65 and over.

Outcome: Catheter-Associated Urinary Tract Infections

The urinary tract is a common site of HAI. Urinary catheter use and specific comorbid conditions can increase the risk of developing a UTI. Approximately 40% of all HAIs are attributed to catheter-associated UTIs (Niel-Weise & van den Broek, 2005).

  Figure 3.2. Adult surgery patients with postoperative catheter-associated urinary tract infection, by race/ethnicity, diabetes status, and gender, 2009-2010

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Source: Agency for Healthcare Research and Quality, Medicare Patient Safety Monitoring System, 2009-2010.
Denominator: Selected discharges of hospitalized patients age 18 and over having major surgery and meeting specific criteria for each measure.
Note: For this measure, lower rates are better. White, Black, and Asian are non-Hispanic. Hispanic includes all races. Data for Asians and Hispanics in 2009 did not meet criteria for statistical reliability.

  • In 2010, Hispanic adult surgery patients had a higher percentage of catheter-associated UTIs than Whites (5.1% compared with 3.4%; Figure 3.2).
  • Also in 2010, adult surgery patients with diabetes had a higher percentage of catheter-associated UTIs than adult surgery patients without diabetes (4.8% compared with 3.0%).
  • In 2010, female surgery patients had a higher percentage of catheter-associated UTIs than male surgery patients (4.0% compared with 2.9%).

Also, in the NHQR:

  • In 2010, adult surgery patients ages 65 to 74, 75 to 84, and 85 and over had a higher percentage of catheter-associated UTIs compared with adult surgery patients under age 65.
  • In 2010, the percentage of adult surgery patients with catheter-associated UTIs was higher for patients with chronic obstructive pulmonary disease (COPD) than for patients without COPD.

Outcome: Central Line-Associated Bloodstream Infections

Patients who require a central venous catheter inserted into the great vessels leading to the heart tend to be severely ill. However, the placement and use of these catheters can result in infections and other complications.

  Figure 3.3. Adult admissions with central venous catheter-related bloodstream infections per 1,000 medical and surgical discharges of length 2 or more days, by patient income and hospital geographic location, 2008-2009

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Key: MSA = metropolitan statistical area.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, and AHRQ Quality Indicators, version 4.1, 2008-2009.
Denominator: People age 18 and over or obstetric admissions.
Note: For this measure, lower rates are better.

  • In 2009, the three lower income groups had worse rates of bloodstream infections than the high-income group (Figure 3.3).
  • Also in 2009, hospitals in large central metropolitan areas had higher rates than hospitals in large fringe metropolitan areas (3.4 per 1,000 discharges compared with 2.8). Hospitals in small metropolitan, micropolitan, and nonmetropolitan areas had lower rates than hospitals in large fringe metropolitan areas (2.1, 1.6, and 0.6, respectively, compared with 2.8).

Adverse Events

Outcome: Mechanical Adverse Events Associated With Central Venous Catheters

Some patients need a central venous catheter inserted into a major vein in the neck, chest, or groin so that providers can administer medication or fluids, obtain blood for tests, and take cardiovascular measurements. Patients who require a central venous catheter tend to be severely ill. The placement and use of these catheters can result in mechanical adverse events, including bleeding; hematoma; perforation; pneumothorax; air embolism; and misplacement, occlusion, shearing, or knotting of the catheter.

  Figure 3.4. Composite: Mechanical adverse events associated with central venous catheter placement, among adults, by race, gender, and age, 2009-2010

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Source: Agency for Healthcare Research and Quality, Medicare Patient Safety Monitoring System, 2009-2010.
Denominator: Selected discharges of hospitalized patients age 18 and over with central venous catheter placement.
Note: For this measure, lower rates are better. White and Black are non-Hispanic. Mechanical adverse events include allergic reaction to the catheter, tamponade, perforation, pneumothorax, hematoma, shearing off of the catheter, air embolism, misplaced catheter, thrombosis or embolism, knotting of the pulmonary artery catheter, and certain other events.

  • In 2010, there were no statistically significant differences by race, gender, or age in the percentage of mechanical adverse events associated with central venous catheter placement (Figure 3.4).

Also, in the NHQR:

  • In 2010, the percentage of hospitalized adults with adverse events associated with central venous catheter placement was higher for adults with obesity than for those without obesity.

Outcome: Obstetric Trauma

Childbirth and reproductive care are the most common reasons for women of childbearing age to use health care services. As 11,300 babies are born each day in the United States (Martin, et al., 2011), childbirth is the most common reason for hospital admission among women.

Obstetric trauma involving a severe tear to the vagina or surrounding tissues during delivery is a common complication of childbirth. Higher risks of severe (i.e., 3rd or 4th degree) perineal laceration may be related to the degree of fetal-maternal size disproportion. Adolescents, who often have smaller body sizes because they have not finished growing, may be more likely to experience obstetric trauma than older women (Riskin-Mashiah, et al., 2002). In addition, although any delivery can result in trauma, existing evidence shows that severe perineal trauma can be reduced by restricting the use of episiotomies and forceps (Kudish, et al., 2008).

Previous reports used AHRQ Quality Indicators version 3.1 to generate obstetric trauma rates. As of 2011, the reports use a modified version 4.1 of the software. While the effects of version change are extremely small, these estimates should not be compared with estimates in previous reports.

  Figure 3.5. Obstetric trauma with 3rd or 4th degree laceration per 1,000 vaginal deliveries without instrument assistance, by race/ethnicity and area income, 2004-2009

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Key: API = Asian or Pacific Islander; Q1 represents the lowest income quartile and Q4 represents the highest income quartile based on the median income of a patient's ZIP Code of residence.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, State Inpatient Databases disparities analysis file, and AHRQ Quality Indicators, modified version 4.1.
Denominator: All patients hospitalized for vaginal delivery without indication of instrument assistance.
Note: For this measure, lower rates are better. Rates are adjusted by age. White, Black, and API are non-Hispanic; Hispanic includes all races.

  • From 2004 to 2009, rates of obstetric trauma with 3rd or 4th degree laceration decreased from 29.8 to 22.8 per 1,000 vaginal deliveries without instrument assistance (Figure 3.5). The rates for all racial/ethnic and income groups decreased.
  • In all years, API mothers had higher rates of obstetric trauma than White mothers. In the same period, Black and Hispanic mothers had lower rates of obstetric trauma than White mothers.
  • From 2004 to 2009, residents of the lower three area income quartiles had lower rates than residents of the highest area income quartile.
  • The 2008 top 4 State achievable benchmark was 17.8 per 1,000 deliveries.iii Hispanic and Black mothers have already attained the benchmark. At the current annual rate of decrease, White mothers could achieve this benchmark in 4 years, while API mothers would take 12 years. All income groups could achieve the benchmark within about 4 years.

Also, in the NHQR:

  • In all years, mothers ages 18-24 and 35-54 had lower rates of obstetric trauma than mothers ages 25-34. Mothers with Medicare, Medicaid, and no insurance had lower rates of obstetric trauma than mothers with private health insurance.

Patient Safety Culture

Measuring patient safety directly is difficult because of the complexity of systematically reporting medical errors and adverse events. High-reliability organizations that achieve low rates of adverse events establish "cultures of safety." A culture of safety is characterized by shared dedication to making work safe, blame-free reporting and communication about error, collaboration and teamwork across disciplines, and adequate resources to prevent adverse events.

AHRQ developed the Hospital Survey on Patient Safety Culture to help hospitals assess the culture of safety in their facilities. AHRQ began producing comparative database reports in 2007 to help hospitals assess their performance relative to similar institutions.

In this NHDR, we present data from the Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report. This report is based on survey responses collected from 567,703 hospital staff in 1,128 hospitals representing approximately 18% of the Nation's hospitals. The average hospital response rate was 53%, with an average of 503 completed surveys per hospital.

Most hospitals administered Web surveys (66%), up from 25% in 2007, when most hospitals administered paper surveys, and up from 56% in 2011. Web surveys resulted in slightly lower response rates (51%) than response rates from paper surveys (61%) but were about the same as mixed-mode administered surveys (49%). Most hospitals administered the survey to all staff or a sample of all staff from all hospital departments. Nurses accounted for more than one-third of respondents. More than three-quarters of respondents had direct interaction with patients.

Results are presented for the 12 patient safety culture composites assessed in the survey, as an average percent positive response. Percent positive refers to the percentage of responses that agree or strongly agree with a positively worded item (e.g., "People support one another in this unit") and the percentage that disagree or disagree strongly with a negatively worded item (e.g., "We have patient safety problems in this unit"). Hospitals contributing data to the comparative database mirror the population of U.S. hospitals as a whole, but participation is entirely voluntary.

Twenty percent of the database hospitals were government owned, which is similar to the distribution of registered hospitals (26% government owned) included in the 2010 American Hospital Association (AHA) Annual Survey of Hospitals. There were few differences between government-owned and non-government-owned hospitals across the 12 patient safety culture composites, with an average of 63% positive across the composites for both types of ownership.

Nearly two-thirds (66%) of the database hospitals were nonteaching, which is slightly lower than the distribution of 2010 AHA registered hospitals (76%). Nonteaching hospitals scored higher than teaching hospitals across all 12 patient safety culture composites.

  Figure 3.6. Average percentage of respondents who did not report any patient safety events, by hospital ownership

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Source: Agency for Healthcare Research and Quality, Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report.
Denominator: Hospital staff responding to the 2011 Hospital Survey on Patient Safety Culture.

  • More staff in government-owned hospitals did not report any events in the past 12 months (59%) than in non-government-owned hospitals (54%; Figure 3.6). It is likely that this represents underreporting of events in both settings.
  • Staff in government-owned hospitals on average gave only slightly higher patient safety grades than staff in non-government-owned hospitals (76% compared with 75% saying "Excellent" or "Very Good"; data not shown).

  Figure 3.7. Average percent positive response for teamwork across units and handoffs and transitions, by hospital teaching status

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Source: Agency for Healthcare Research and Quality, Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report.
Denominator: Hospital staff responding to the 2011 Hospital Survey on Patient Safety Culture.

  • Nonteaching hospitals on average scored 5 percentage points higher on Teamwork Across Units (60% positive compared with 55%), and Handoffs and Transitions (47% positive compared with 42%; Figure 3.7).
  • Nonteaching hospitals on average had a slightly higher patient safety grade (76% compared with 73% saying "Excellent" or "Very Good"; data not shown). Yet the same percentage of nonteaching and teaching hospital staff on average did not report any events in the past 12 months (55%; data not shown).

References

Aspden P, Corrigan J, Wolcott J, et al. Patient safety: achieving a new standard of care. Washington, DC: Institute of Medicine, Committee on Data Standards for Patient Safety; 2004.

Encinosa WE, Hellinger FJ. The impact of medical errors on 90-day costs and outcomes: an examination of surgical patients. Health Serv Res 2008 Dec;43(6):2067-85. Epub 2008 Jul 25.

Gastmeier P. Nosocomial infection surveillance and control policies. Curr Opin Infect Dis 2004 Aug;17(4):295-301.

Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003 Mar 5;289(9):1107-16.

Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Hlth Rep 2007;122:160-6.

Kohn L, Corrigan J, Donaldson M, eds. To err is human: building a safer health system. Institute of Medicine, Committee on Quality of Health Care in America. Washington, DC: National Academy Press; 2000.

Kudish B, Sokol RJ, Kruger M. Trends in major modifiable risk factors for severe perineal trauma, 1996-2006. Int J Gynaecol Obstet 2008 Aug; 102(2):165-70.

Martin JA, Hamilton BE, Ventura SJ, et al. Births: final data for 2009. Natl Vital Stat Rep 2011; 60(1).

Mayr FB, Yende S, Linde-Zwirble WT, et al. Infection rate and acute organ dysfunction risk as explanations for racial differences in severe sepsis. JAMA 2010 Jun 23;303(24):2495-2503.

Moore LJ, Moore FA, Todd SR, et al. Sepsis in general surgery: the 2005-2007 National Surgical Quality Improvement Program perspective. Arch Surg 2010 Jul;145(7):695-700.

Niel-Weise BS, van den Broek PJ. Antibiotic policies for short-term catheter bladder drainage in adults. Cochrane Database Syst Rev 2005;3.

Riskin-Mashiah S, O'Brian Smith E, Wilkins IA. Risk factors for severe perineal tear: can we do better? Am J Perinatol 2002;19(5):225-34.

Shreve J, Van Den Bos J, Gray T, et al. The economic measurement of medical errors. Schaumberg, IL: Society of Actuaries/Milliman; 2010.

U.S. Department of Health and Human Services. 2012 annual progress report to Congress. National Strategy for Quality Improvement in Health Care. April 2012, corrected August 2012. Available at: http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf [Plugin Software Help]. Accessed March 8, 2013.


i. Calculated by Noel Eldridge of the Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality. This number is a subset calculation based on the medication-related measures that were used to calculate the overall hospital-acquired condition rate for 2010.
ii. Patient Safety and Quality Improvement Act of 2005, 42 U.S.C. 299b-21 to 299b-26.
iii. The top 4 States that contributed to the achievable benchmark are South Dakota, Utah, West Virginia, and Wyoming.

Page last reviewed May 2013
Internet Citation: 2012 National Healthcare Disparities Report: Chapter 3. Patient Safety . May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/chap3.html