Snapshot of Patient Safety in U.S.: Findings from the 2009 National Healthcare Quality and Disparities Reports

Findings: Of the 33 hospital measures related to safety, only12 (36%) improved at a rate greater than 5% per year. In contrast, of the 19 hospital measures not related to safety, 16 (84%) improved at a rate greater than 5% per year. While more than half of safety measures showed some improvement, hospital patient safety measure improved at a much slower rate than general hospital quality measures. Of all the measures in the NHQR measure set, the one worsening at the fastest rate is postoperative sepsis (Table 3). The two process measures related to HAIs tracked in the NHQR, both covering timely receipt of prophylactic antibiotics for surgery, are improving steadily. - Adult surgery patients who received prophylactic antibiotics within 1 hour prior to surgical incision (annual rate of improvement is 26.4%). - Adults surgery patients who had prophylactic antibiotics discontinued within 24 hours after surgery end time (annual rate of improvement is 32.9%). However, HAI outcome measures are lower rates of improvement or no improvements. - Adults surgery patients with postoperative pneumonia (11.6% annual rate of improvement). - Bloodstream infections associated with central venous catheter placements (no change) - Selected infections due to medical care (-1.6% rate of improvement).

Other selected findings on patient safety include:

Deaths following complications of care • From 2001 to 2006, 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 116.8 per 1,000 in 2006). In 2006, Hispanics had a higher rate of in-hospital deaths following complications of care than non-Hispanic Whites (122.1 per 1,000 compared with 117.1 per 1,000). (HCUP 2001-2006) Adverse drug events • In 2007, adverse drug events in the hospital related to some frequently used medications ranged from 3.4% to 8.9% of all hospitalized Medicare patients. (CMS MPSMS 2006)

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.