Posted by Sten Westgard, MS
Here's an eye-opening report from the Office of Inspector General from the Department of Health and Human Services: Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries
So what's your best guess on the frequency of adverse events?
- "13.5% of hospitalized Medicare beneficiaries experienced adverse events during their hospital stays." That's about 1 in 7. It projects to an estimated 134,000 adverse events affecting Medicare beneficiaries each month.
- "An estimated 1.5% of Medicare beneficiaries experienced an event that contributed to their deaths." That projects to about 15,000 patients in a single month.
- "An additional 13.5% of of Medicare beneficiaries experienced events during their hospital stays that resulting in temporary harm."
- "44 percent of adverse and temporary harm events were clearly or likely preventable."
- About 3.5% of the Medicare costs during the study period were a result of adverse events. This means an estimated $324 million was spent on adverse and temporary harm events. On an annual basis, this could mean a projected $4.4 billion dollars a year are spent on errors.
- One bit of good news, perhaps: "Less than 1 percent...experienced an event on the NQF list of Serious Reportable Events." That actual number was an estimated 0.6 percent.
What's even more frightening from our perpsective is that this study tracked only a select list of adverse events. There were no attempts to track laboratory errors (either pre-analytical, analytical, or post-analytical errors). So the numbers here are actually optimistic, having underestimated the number of errors.
This was a study from 2010 that reviewed one month - October 2008 - of Medicare beneficiary medical records. We've only recently been covering error rates on this blog, so we didn't cover it when the report was first issued.
For a moment, let's trot out the short-term Sigma rates for these errors:
- 13.5% adverse event rate = About 2.6 Sigma
- 1.5% death-contributing error = About 3.7 Sigma
- 0.6% Serious Reportable Events = About 4.0 Sigma
We're still a long way from Six Sigma. And that's when we ignore any errors associated with the laboratory.