Highlight on Connecticut: Fewer injuries at hospitals in 2014, but implications unclear

A report prepared by the Connecticut Department of Public Health (Department) showed that the number of adverse events reported by the state’s hospitals dropped from 534 to 471 or, by 12 percent, in 2014. However, despite the decrease in the amount of such events, the Department also noted that the number still remains higher than in 2012, during which 241 events were reported. Additionally, the number of adverse event reports alone may not provide the basis for an accurate comparison of the hospitals because, as the Department pointed out, the data may have been influenced by a variety of a factors, including how effective the hospitals were at reporting adverse events.

Adverse Events

An “adverse event” is “an injury caused by or associated with medical management that results in death or measurable disability.” Adverse events may not always arise from medical errors. Four categories of adverse events accounted for 89 percent of all those reported by Connecticut hospitals in 2014. The most commonly reported adverse events included pressure ulcers acquired after admission to a health care facility, which accounted for 52 percent or 245 of all events. Seventy-eight reports related to falls that resulted in serious disability or death, which accounted for 17 percent of all reported events. Perforations that occurred during procedures were included in 70 reports or 15 percent of events, and hospitals submitted 24 reports of foreign objects remaining in patients after surgeries, which accounted for five percent of all events. The Department noted that the number of reports in each of the event categories decreased between 2013 and 2014.

Increased Events.

While the overall number of adverse events decreased, some categories of reported events saw an increase in 2014. These included patient deaths or serious injuries associated with contaminated drugs, devices, or biologics provided in health care settings, which  increased from zero in the prior year to three in 2014. Additionally, nine instances of sexual abuse or assault on a patient or staff member were reported for the year, which was an increase from the four that were reported in the previous year.

Breakdown of Events

Acute care or children’s hospitals submitted 415 adverse event reports, which constituted 88 percent of all reports. Chronic disease hospitals submitted 42 event reports and independent outpatient surgical facilities submitted 13 reports. Hospitals for the mentally ill submitted only one adverse event report. Fifty-one percent of the reported events occurred in males, while 49 percent occurred in females, and the majority of the reports involved patients who were over 65 years old. Additionally, the most common location of adverse events was in adult medical wards.

Hospital Rates

The highest number of adverse events were reported by the largest hospitals in the state. For instance, Yale-New Haven Hospital had the highest number of reported events at 80 and St. Francis Hospital was second, with 52 events. However, the report also calculated the rates of adverse events per patient days and the found that Bristol Hospital had the highest rate of 42.5 errors per 100,000 patient days, followed closely by Danbury Hospital at 41.3. The average for all acute care hospitals in Connecticut was a rate of 21 errors per 100,000 patient days.

Data Limitations

The Department cautioned that the event data may have been influenced by a variety of factors such as patient case mix, number of patients, quality of care, event definitions, reporting requirements, and willingness to report events. As a result, the Department stated, “We cannot say whether a high reporting rate reflects highly complete reporting in a facility with good quality of care, or perhaps modestly complete reporting in a facility with poor care, or neither better nor worse quality care. . .”

Concerns

Lisa Freeman, Director of the non-profit Connecticut Center for Patient Safety (CTCPS) said in a statement to the CT Post, “Unfortunately, there are still too many events that should not be occurring, and too many patients and their families suffering the consequences.” Freeman added, “Our state still has work to do to move closer to eliminating harm to patients.”