200965 A Snapshot of Patient Safety in U.S.: Findings from the 2008 National Healthcare Quality and Disparities Report

Monday, November 9, 2009: 2:45 PM

Karen Ho , AHRQ, Rockville, MD
Study Design:

Data come from the 2008 National Healthcare Quality Report and National Healthcare Disparities Report, which compiled national estimates over 200 measures of health care quality from more than 35 different data sources. Analyses for this study will focus on 7 measures of patient safety in 3 areas: surgical complications, other complications of hospital care and complications of medications. An analysis of disparities for each of these measures compare whites with blacks, Asians, American Indians and Alaska Natives and Hispanics. For each core measure, disparities are measured in both absolute and relative terms. Disparities for a baseline year and for the most current year of data are compared to assess trends in disparities.

Findings: Data from the NHQR shows that patient safety measures had an overall decline in improvement, with only 45% of the measures showing at least some improvement.

Selected findings include:

Deaths following complications of care

From 2001 to 2005, there was significant improvement overall in the rates of in-hospital deaths following complications of care (from 152.2 per 1,000 in 2001 to 125.8 per 1,000 in 2005). In 2005, Hispanics had a higher rate of in-hospital deaths following complications of care than non-Hispanic Whites (131.0 per 1,000 compared with 125.2 per 1,000). (HCUP 2001-2005)

Adverse drug events

In 2006, adverse drug events in the hospital related to some frequently used medications ranged from 5.2% of Medicare patients who received low-molecular-weight heparin to 15.5% of Medicare patients who received intravenous heparin. Blacks were more likely than Whites to have an adverse drug event for low-molecular eight heparin (6.3% compared with 5.2%) and warfarin (9.0% compared with 5.9%). (CMS MPSMS 2006)

Inappropriate medications for older patients

From 1996 to 2005, the percentage of older patients who reported purchasing at least 1 of 33 potentially inappropriate drugs decreased significantly, from 21.3% to 17.7%. In 2005, older Asians were more likely than older Whites to have inappropriate drug use (20.3% compared with 17.3%). (MEPS 2005)

Conclusions: The NHQR and NHDR shows that improvement has slowed for many patient safety measures. While progress has been made in raising awareness of the importance of patient safety by improving event reporting systems, and establishing national standards for data collection, systems for identifying and learning from patient safety events need to be improved. For some measures where data is available, Asians and Hispanics are more likely to experience adverse events.

Learning Objectives:
Describe the National Healthcare Quality Report and the National Healthcare Disparities Report and the kind of data that are found in these annual reports. Discuss measurement issues in patient safety and challenges in tracking and monitoring patient safety. Identify patient issues that are improving and those that are worsening over time.

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the Lead Staff of the National Healthcare Disparities Report for which the data and measures for this study is based.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

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