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Weinstock M. Hosp Health Netw. 2011 Apr;85:46-49, 2.
This article discusses one hospital system's effort to hardwire safety into daily work by having providers look at each patient as a loved one.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Journal Article > Study
Naessens J, Campbell CR, Shah N, et al. Am J Med Qual. 2012;27:48-57.
The epidemiology of adverse events on a population basis has been well studied, but how these data translate to risks for individual patients is not as clear. The likelihood of suffering an adverse event is directly tied to length of hospitalization, and this study sought to evaluate a complementary question: whether patients who are more severely ill at admission are at increased risk of preventable harm. By linking adverse event data from various sources—including Patient Safety Indicators, voluntary error reports, and infection control reports—to clinical databases, the authors were able to show that higher illness severity is associated with an increased risk of adverse events during hospitalization. These findings are supported by the fact that intensive care unit patients have consistently been shown to experience more adverse events. An AHRQ WebM&M commentary discusses a case of a medication error occurring in an acutely ill patient with multiple underlying comorbidities.